Tim Church, M.D., M.P.H., Ph.D. John S. McIlhenny Endowed Chair Pennington Biomedical Research Center

Transcription

1 Diabetes- What Do You Need to Do Tim Church, M.D., M.P.H., Ph.D. John S. McIlhenny Endowed Chair Pennington Biomedical Research Center 1

2 Common Myth: You have to run a marathon to benefit from regular physical activity! 2

3 Fitness Testing Maximal exercise test on a treadmill (Balke) Standardized d fitness categories es based on age, gender & time on treadmill: Fitness => measure of physical activity habits 3

4 Low Fitness = Unfit Fitness Classifications Lower 20% time on treadmill for gender and age Moderate Fitness- Next 40% time on treadmill for gender and minutes of walking per week High Fitness- Highest 40% time on treadmill for gender and age 4

5 CVD Mortality Rates by Fitness: Aerobic Center Longitudinal Study (ACLS) Deaths per 10,000 person-y years Low Moderate High Women Men Blair SN et al. JAMA 1989;262:

6 Fitness and All-Cause Mortality, ACLS Men, Adjusted Death Rate per 10,000 PY % Upper Limit Expected Expected Relation Relation Adjusted Death Rate 95% Lower Limit GXT Test Performance (minutes) 6

7 Fitness and All-Cause Mortality, ACLS Men, Adjusted Death Rate per 10,000 PY % Upper Limit Expected Relation Adjusted Death Rate 95% Lower Limit GXT Test Performance (minutes) 7

8 CVD Mortality by Fitness Men with Diabetes r) 160 CVD Death Rate (per 10K man-year <7 7 to to to to t o to 12.9 >13 Mets Church et al, Arch Int Med,

9 Diabetes Incidence Rates By Diabetes By Fitness Groups, Men (n=8633) Di iabetes incidence e/1000 men Low Moderate High Cardiorespiratory Fitness Groups Wei M et al. Ann Int Med

10 Diabetes Incidence Rates by Fitness: ACLS (n =13,190) 45 Rate per 1,0 000 man-yrs P trend < < unpublished Maximal METs 10

11 Health Benefits of Aerobic & Resistance Training in Individuals with Diabetes: HART-D Tim Church, M.D., M.P.H., Ph.D. Pennington Biomedical Research Center 11

12 Most national organizations recommend individuals with diabetes participate in exercise program composed of a combination of aerobic and resistance training for maximal health benefits 12

13 Effect of Exercise Type on HbA1c N =251 & 6 month intervention Sigal, RJ et al. Ann Intern Med ;147(6):

14 Effect of Exercise Type on HbA1c N =251 Primarily Caucasian a (92%) 70% Men No insulin users Fairly healthy participants Sigal, RJ et al. Ann Intern Med ;147(6):

15 Exercise Prescription Sigal et al Aerobic 135 min/wk Resistance 135 min/wk Combo 270 min/wk Was it the combination of AT & RT or time? 15

16 HART-D NIDDK funded Primary Outcomes Published Church et al, JAMA Nov Participants: Sedentary individuals with diabetes HbA1c: >6.5% but <11.0% Tried to be VERY inclusive 16

17 HART-D Compare benefit to HbA1c of: Control group Stretching Aerobic training (AT) 12 kcal/kg/week Resistance training i (RT) 3 days per week: 21 sets per day Combination of RT & AT (Combo) 10 kcal/kg/week & 1 set of 9 RT 2 days/week 9 Month Intervention All exercise supervised (@ 20K sessions) 17

18 HART-D Primary Outcomes: Hemoglobin A1c Secondary Outcomes: Fitness and strength DEXA 18

19 Telephone screens n = 2421 Completed assessment (n = 1,924) Randomized n = 262 Control n = 41 RT n = 73 AT n = 72 Combo n = 76 STOPPED ENROLLMENT 19

20 Participants Age Mean (SD) 55.8 (8.7) Female 63.0% Ethnicity/race, % African-American 43.5% White 52.7% Other 3.8% Body Mass Index 34.9 (5.9) Waist Circumference, cm 112 (13.8) Relative VO2, ml/kg/min 19.2 (4.2) METs 69(13) 6.9 (1.3) HbA1c, % Duration Diabetes, years 7.7 (1.0) 7.1 (5.5) 20

21 Participants Antidepressant Medication 18% Previous Myocardial Infarction 2% Previous Cardiac Catheterization 18% Coronary Artery By-Pass 5.0% Neuropathy 17.6% Low-density Lipoprotein 96 (29) High-density Lipoprotein 49 (11) Cholesterol Medications 64% Systolic BP, mmhg 126 (13) Diastolic BP, mmhg 76 (8) Blood Pressure Medications 79% 21

22 Hart-D DM Medication Use Any 97.3 Biguanides (metformin) 65% Sulfonylureas (glipizide) 24% Thiazolidinediones (glitazones) 18% Combination Drugs 16% Incretin Mimetics (exenatide) 10% DPP-4 Inhibitors (sitagliptin) 5% Meglitinides 3% Insulin 18% TOTAL (combo counted 2X) 176% 22

23 Retention & Compliance Retention: ti 94% with follow-up dt data All participants used in analysis Compliant (>70% adherence): Aerobic: 72% Resistance Training: 82% Combo: 82% 23

24 HART-D Intervention ti Data 24

25 RT Group 25

26 Resistance: Combo Group 26

27 Aerobic Training: AT & Combo Aerobic Group Sessions/Week Intensity, % peak V Speed, MPH Grade, % Mean METs level Time, min/wk Combo Group 3x/wk Mod/Vig Speed ~ Grade METs Time Sessions/Week Intensity, % peak VO Speed, MPH Grade, % Mean METs level Time, min/wk Month 3 & 6 removed for presentation purposes 27

28 MET-Minutes/WeekMinutes/Week 2008 Physical Activity Recs 28

29 Time Exercising Resistance 141 min/wk Aerobic 140 ( ) min/wk Combo RT: min/wk AT: 110 ( ) min/wk 29

30 HART-D Intervention Goals Achieved!!! Total exercise time similar across groups Delivered aerobic interventions that met current recommendations 30

31 Steps per Day: Exercise Groups 31

32 Steps per Day: Exercise Groups No change in caloric intake as assessed by FFQ 32

33 HART-D Outcome Data 33

34 HbA1c by Month and Group 7.80 Intention-toTreat totreat Analysis (n=262) 7.70 Control HbA1c, % Resistance Aerobic Combo Month 34

35 Control Subtracted Change in HbA1c after 9 months P =

36 HbA1c: Baseline > 7.0% & PPT P = 0.04 P =

37 Improve HbA1c 0.5% or Decrease DM Medications 37

38 Strength Testing * * *Different from all other groups 38

39 METs: From Speed & Grade Sig vs. Control & RT 39

40 Waist Circumference All Sig Vs Control 40

41 Weight Sig. vs Control & RT 41

42 DEXA Data Sig. Vs. Control Sig. Vs. Control & AT Sig. Vs. AT & Combo 42

43 Summary For a given amount of time a physical activity program composed of aerobic and resistance is superior to either activities alone Blood sugar control Fitness Fat Mass The HART-D combination program consisted of: 110 minutes per week of mod/vig intensity walking 2 days of 9 resistance training exercises each 10 to 12 repetitions per exercise ~20 minutes per day 43

44 How Do My Recommendations (opinions) Compare to New Federal Guidelines? 44

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49 30 minutes 49