Exercise Prescription for Diabetes/ Prediabetes Diabetes/ Prediabetes Dr. Laleh Hakemi Internist Vice President of Women Affairs of the SMFI

Transcription

1 Exercise Prescription for Diabetes/ Prediabetes Diabetes/ Prediabetes Dr. Laleh Hakemi Internist Vice President of Women Affairs of the SMFI

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3 LIFE STYLE CHANGE IS BY FAR THE MOST EFFECTIVE INTERVENTION

4 the U.S. Diabetes Prevention Program reported a 58% reductionin incidence of T2DM 4-yearlifestyle intervention (150 min/week moderateactivity exercise +dietary change program designed to induce a 7% weight loss). The patients actually completed on average approximately 300 min/week at this intensity.

5 Finish Diabetes Prevention Study A similar risk reduction of 58% 210 min/week moderate to strenuous intensity exercise (including resistance training) + dietary intervention to reduce fat and increase fiber intake patients completing an average of 204 min/week of exercise.

6 Asian Indians with IGT 210 min/week of brisk walking 28.5% risk reduction of incident diabetes

7 Da Qing Study from China reported a 46% risk reduction moderate intensity activity was prescribed 140 min/weekand 280 min/week for persons 50 years and <50 years Patients in this study actually completed on average 560 min/week of exercise at moderate intensity.

8 Japanese Diabetes Prevention Program min/week of moderateintensity exercise reported a risk reduction of 67%.19

9 Poor glycemic control accelerated cardiovascular,renal and ophthalmic diseases elevated morbidity and mortality. Therefore, glycemic control has traditionally Therefore, glycemic control has traditionally been the primary focus of exercise training studies in patients at risk or with T2DM.

10 SigalRJ,Kenny GP, Boule NG, et al. Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med 2007;147: Beneficial effects (glycemic control) Aerobic Resistance combination of both (synergistic): greater results than each mode alone.

11 mechanisms responsible for these exercise training-induced benefits They are complex : Improvements in insulin sensitivity, Improvements in insulin dependent glucose uptake from increases in muscle GLUT4 number and function increases in muscle capillarization and blood flow. These adaptations are strongly influenced by energy expenditure.

12 Exercise works through all phases of prevention

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14 The benefits of exercise training close association of aging and diabetes efforts to reduce the effect of sarcopenia improvements in glycemic control Improvements in physical function and independence. It is widely accepted that anabolic resistance exercise is the only antidote to the loss of lean tissue accompanying hypocaloricdiets to reduce weight in this cohort. decreasing body fat and improving lean mass in patients with T2DM metabolic improvements more closely related to a loss of visceral adiposity rather than weight loss in general. although, these improvements may not be necessary to induce improvements in glycemic control.

15 The benefits of exercise training Exercise and Sport Science Australia-2016 Cardiorespiratory fitness are well reported, approximately 12% improvement. Greater improvements with higher intensities of aerobic training or interval training, although data on interval training in T2DM is lacking. Improvement in cardiorespiratory fitness is very pertinent given the association with cardiovascular risk factors, cardiovascular-related mortality and all cause mortality.

16 Each 1-MET increase in exercise capacity conferred a 12 percent improvement in survival. Jonathan Myers, Ph.D.et al The New England Journal of Medicine, March 2002

17 Aerobic training: maximize caloric expenditure improvements in cardiorespiratory fitness Resistance training: related to improvements in insulin sensitivity and GLUT4 number and function.

18 strength endurance <6 reps 8-15 reps >15 reps High Moderate Low intensity intensity intensity To achieve a balanced increase in endurance and strength, 8-12 reps are ideal

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20 Other co-morbidities in diabetics osteoarthritis, peripheral vascular disease, Mobility impairment, peripheral neuropathy elevated fall risk, depression, cognitive impairment. In all of these conditions, targeted exercise prescriptions (aerobic, resistance, balance training and multi-modal exercise programs)

21 Benefits of Long Term Exercise In well-controlled diabetics Improvement of the respiratory system status Minimizing risk factors for cardiovascular disease: decrease in body fat, Improving lipid profile, lowering BP Retardation or stopping large vessel or heart disease Improving blood glucose level control Decrease in uric acid 1-2% decrease in Hb A1C Decrease in the need for hypoglycemic drugs Improving O2 uptake by tissues Improving muscular status: increase in power and muscle mass Improving joint motion, decreasing osteoporosis Weight loss Increase in self- confidence Improving independence Improvement in quality of life Increasing work capacity Decreasing mortality rate

22 EXERCISE IS MEDICINE

23 mode intensity duration frequency M I D F frequency intensity time type F I T T

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26 med1 Other disease Med patient med2 diet exercise

27 A position statement from Exercise and Sport Science Australia Based on the evidence, it is recommended that patients with T2DM or pre-diabetes accumulate a minimum of 210 min per week of moderateintensity exercise or 125 min per week of vigorous intensity exercise with no more than two consecutive days without training. Vigorous intensity exercise is more time efficient and may also result in greater benefits in appropriate individuals with consideration of complications and contraindications. It is further recommended that two or more resistance training sessions per week (2 4 sets of 8 10 repetitions) should be included in the total 210 or 125 min of moderate or vigorous exercise, respectively. It is also recommended that, due to the high prevalence and incidence of comorbid conditions in patients with T2DM, exercise training programs should be written and delivered by individuals with appropriate qualifications and experience to recognize and accommodate comorbidities and complications Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

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29 Comparing mod to high intensity The 1.7 multiplication factor was derived from recommendations that 150 min of moderate intensity = 90 min of vigorous physical activity (a ratio of 1:1.7).

30 a recent study : uphill walking (4 4 min / 90 95% HR peak with 3 min active recovery between bouts) more effective in reversing the risk factors of the metabolic syndrome than moderate intensity exercise. 2recent studies : short-term sprint interval training increases insulin sensitivity in healthy sedentary adults. While vigorous intensities of exercise (both aerobic and resistance) may be a preferable option for some patients, for a large majority of people at risk or with T2DM, moderate intensities of exercise may be more appropriate,better tolerated and result in greater exercise adherence.

31 If the recommended levels of exercise cannot be achieved, achieve what they can. This will still result in health benefits. Given the close association with T2DM and obesity, sum of 250 min / week is recommended for overweight patients if weight loss is also a goal.

32 A rational program for starting: 10 min warm up and stretching then, 20 min mild aerobic exercise 10 min cool down regular, at least 3 times/wk gradual increase in duration & intensity fixed interval between the session and insulin injection or meal

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34 STAND UP Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health science of sedentary behavior. Exerc Sport Sci Rev 2010;38: Elevated volumes and uninterrupted durations of sedentary behavior predictive of poor glycemic control, independent of moderate to vigorous-intensity activity in people at risk of developing T2DM. Further, light-intensity (incidental) activity may also play an important protective role although this activity should be seen as additional to, and not a substitute for, moderate or vigorous intensity activity. It is recommended that patients with T2DM or pre-diabetes minimize sedentary behavior by breaking these periods with frequent bouts of light-intensity activity or incorporating regular breaks that involve standing up from a seated position.

35 Regulatory hormones and actions Insulin: glucose transfer into cell and promotes glycogen synthesis; glucagon secretion; gluconeogenesis; converts glucose to TG in lipid tissue Glucagon: hepatic glycogenolysis and gluconeogenesis Catecholamines: hepatic glycogenolysis and gluconeogenesis Epinephrine: insulin secretion Norepinephrine: peripheral glucose utilization GH: CHO metabolism; neutralizes FFA Cortisol: peripheral glucose utilization; gluconeogenesis

36 Prevention of injuries PPE Venue safety Proper technique Appropriate sports equipment in terms of both quality and size Appropriate program in terms of intensity and frequency Good warm up and cool down Appropriate nutrition Appropriate classification (age, size, maturity, performance) First aid and medical aid Good rehabilitation Hygienic and psychic status

37 SAFETY Plenty of water Measurement of blood glucose, ketone Increase in cal intake 1-3 Hr before exercise if > 30 min duration 20-30% decrease in insulin dose if training is of high intensity or > 30 min duration Insulin injection to a site other than exercising part Availability of fast absorbing CHO gr fast absorbable CHO each 30 min Slow absorbable CHO immediately after exercise

38 DM: Acute consequences may experience hypoglycemia or hyperglycemia with exercise delayed hypoglycemia usu hr but may occur up to 28 hr

39 HYPOGLYCEMIA UNAWARENESS

40 Pharmacokinetics of most commonly used insulin preparations

41 OHA Biguanides Sulfonylureas Meglitinides Alpha-Glucosidase Inhibitors Thiazolidinediones DPP4 inhibitor (Ziptin) GLP-1 receptor agonists (Exenatide)

42 Chronic Complications MICROVASCULAR COMPLICATIONS retinopathy, nephropathy, neuropathy, MACROVASCULAR COMPLICATIONS coronary artery disease, peripheral vascular disease, CVA.

43 ATHEROSCLEROSIS DM significantly increases the risk for heart disease and stroke CAD Peripheral arterial disease Cerebro-Vascular Disease

44 the risk of a cardiac event during exercise cannot be ignored, the cardiac risk of patients with T2DM or prediabetes remaining inactive is greater. Cardiac screening+ ETT is recommended for previously sedentary patients with additional CV risk factors, especially for those attempting to undergo more than brisk walking, although clinical judgment should prevail.

45 CAD PPE ETT if: CAD Age > 35 yr Duration of DM > 10 yr Retinopathy Microalbuminuria Overt nephropathy Peripheral vascular disease DM + other risk factor for CAD Autonomic neuropathy Angina and equivalents Availability of aspirin Gradual increase in severity and duration

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47 Retinopathy Annual ophthalmologic visit Limitations: Head trauma Contact sports Valsalva maneuver Jumping High impact exercise SBP > 170 mmhg Recent surgery or photocoagulation

48 Diabetic Neuropathy 10-18% of patients have evidence of nerve damage at the time their DM is diagnosed: even in prediabetics. Treatment of diabetic neuropathy is less than satisfactory. Improved glycemiccontrol will improve nerve conduction velocity, but symptoms of neuropathy may not necessarily improve. Risk factors for neuropathy such as HTN & HLP to be treated. Avoidance of neurotoxins (alcohol) and smoking, supplementation with vitamins for possible deficiencies (B 12, folate;) Intensive diabetes therapy markedly delays or prevents the development of clinically manifest diabetic polyneuropathy as confirmed by objective nerve function testing in patients with insulindependent diabetes mellitus. Vitamin B12 levels are 30% lower during metformin treatment. Currently, evidence does not support supplementation of the diet with vitamins, antioxidants (vitamin C and E), or micronutrients (chromium) in diabetes

49 Autonomic neuropathy Mild to moderate exercise Limitations: Sudden positional change Extreme temperature High impact exercise High risk environments

50 Diabetic foot Prevention of diabetic foot Trauma Appropriate foot wear Daily inspection Avoid drying Nephropathy Avoid hypoglycemia Avoid dehydration Limitations: Straining High impact

51 Osteoporosis prevention must be started from childhood

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53 Osteoarthritis & PAIN exercise as treatment: weight reduction, improved muscle tone, reduced atrophy, increased flexibility, improved biomechanics low-impact, low-intensity emphasis on strength and flexibility aquatic- machines

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55 Myocarditis Strenuous activity and exercise should be avoided until ECG returns to NL

56 participation allowance: Not allowed if systemic symptoms fever cough myalgia chest pain resting tachycardia excessive shortness of breath palpitations wheezing excessive fatigue lymphadenopathy headache If no systemic symptoms: mild exercise allowed until disappearance of symptoms mod. exercise as soon as the symptoms subsided

57 External Otitis Abstain from water sports 7-10 days, in less severe infection 2-3 days if severe enough to need systemic AB, activity restricted until resolution of symptoms Risk factors: 1-spending long times in the water with the ears submerged 2-unchlorinated, fresh, hot, or contaminated water 3-not removing the water from the ears after swimming 4-introducing dirty objects into the ear 5-irritant substances in water 6-constant use of OTC eardrops

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59 ADA Standards of Medical Care in Diabetes 2016 guidelines

60 Monitoring and glycemic targets HbA1c >=2/year in diabetics on stable regimens who have achieved target HbA1c & 4/year in patients who don t meet the criteria. HbA1c measurement alone is insufficient to evaluate glycemic variability or hypoglycemia; SMBG is required. The HbA1c goal for most nonpregnantadults is <7%. In young patients without other comorbidities, clinicians might consider a more stringent of <6.5%, whereas a less stringent target in patients with extensive comorbid conditions or limited life expectancy. Raising glycemic targets for several weeks can help reverse hypoglycemic unawareness. For most noncritical hospitalized patients, BS of 140 to 180 mg/dl are recommended (A rating); for cardiac-surgery patients and those with ACS or neurologic events, glucose levels of 110 to 140 mg/dl can be considered (C rating).

61 Medical management Encourage a minimum of 150 minutes weekly of moderate-intensity aerobic activity. Type 1 DM: Intensive insulin therapy ( 3 daily injections) or continuous SQ insulin (vs. 1 or 2 daily injections) clearly lowers risk for microvascular & cardiovascular complications. Type 2 DM: Metformin is the initial medication/it can be used (dose reductions) in GFR as low as ml/min/1.73 m 2. BP goal <140/90 mm Hg. The guideline specifically advises against a lower goal (<130/70 mm Hg) in older. The initial agent should be an ACE-I or an ARB, but not both. Statins are recommended for most with age 40. Adding ezetimibeto a moderate-intensity statin can be considered for patients with recent ACS or for patients who are unable to tolerate higher-dose statins. Combination therapy with a statin plus a fibrate generally is not recommended (A rating). Similarly, combination therapy with a statin plus niacin is not recommended and might confer excess risk for CVA (A rating). Antiplatelet therapy: Low-dose ASA is recommended for primary prevention of cardiovascular disease in patients with type 1 and type 2 DM, if 10-year arteriosclerotic cardiovascular disease risk is >10%; it is not recommended if risk is <5% (C rating).

62 Microvascularscreening and management Eye examinations: a complete eye exam should be performed annually by an ophthalmologist or optometrist. Peripheral neuropathy: FDA-approved medications to treat diabetic neuropathy include pregabalin, duloxetine, and tapentadol. Other agents, including TCA, gabapentin, venlafaxine and carbamazepine, also can be considered.

63 PROCESS OF EXERCISE PRESCRIPTION PPE PARACLINIC PRESCRIPTION MEDICATION RED SIGNS MONITORING

64 PPE Hx Phex Para clinic

65 ADA provider recognition measures

66 ETT

67 Ophthalmologic examination schedule It is the leading cause of blindness among working-age adults

68 Strength and endurance Flexibility training Cardiovascu lar training Activity of Daily Living M overload mod Mod to severe mod I rep sec >20 min >30 min D(T) 2-3 days a week 3-7 days a week 3-6 days a week 5-7 days a week F NOT TO DO RED SIGNS MEDs Next visit

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