Rocky Mountain Metabolic Syndrome Symposium May 10, 2014 Exercise and the Metabolic Syndrome Edward L. Melanson, Ph.D. Associate Professor Division of Endocrinology, Metabolism, and Diabetes/ Division of Geriatric Medicine University of Colorado Anschutz Medical Campus Learning ObjecNves 1. Describe how much physical acnvity one should perform to reduce risk of the metabolic syndrome 2. List the pre- exercise screening consideranons for the high risk panent 3. Describe how sedentary behavior affects the metabolic syndrome. Describe how one could modify their behavior to reduce the impact of sedentary behavior on metabolic health Exercise Exercise Versus Physical AcNvity Planned and structured bodily movement done to increase caloric expenditure or strength Examples include jogging, lap swimming, basketball, resistance training Physical AcNvity Bodily movement produced by skeletal muscle that results in energy expenditure Exercise is a type of physical acnvity, as are acnvines of daily living such as climbing stairs, gardening and walking the dog
Physical AcNvity and The Metabolic Syndrome He et al., Endocrine, 2013 Physical AcNvity Guidelines How much physical acnvity is required to: Reduce risk of chronic disease 150-200 mins per week (~1000 kcal/wk) of moderate- intensity, accumulated, physical ac?vity Prevent weight gain 200-300 min per week of moderate- intensity physical ac?vity per week may facilitate the long- term maintenance of weight Induce weight loss > 300 mins per week of moderate- intensity physical ac?vity to promote weight loss and decrease risk of weight gain
What is moderate and vigorous intensity exercise? 1 MET is assumed to represent the energy expenditure (oxygen consumpnon) of total rest METs used to describe intensity of exercise An exercise that requires 5 METs increases energy expenditure 5X above resnng Moderate- intensity (3-6 METs) equivalent to a brisk walk and nonceably accelerates the heart rate Vigorous- intensity (>6 METs) exemplified by jogging; any acnvity that causes rapid breathing and a substannal increase in heart rate. Revised ACSM/CDC (2007/2011) Healthy adults, minimum of 30 minutes moderate- intensity aerobic (endurance) acnvity 5 days each week, or 20 minutes vigorous 3 days per week Must be done in addi?on to ac?vi?es of daily living AcNviNes that maintain or increase muscular strength two days each week 8-10 exercises, 8-12 sets at resistance that induces substan?al fa?gue Minimum goal is 450-475 MET. min/wk (2011:500-100 MET. min/ wk) 1 MET. min 0.017 kcal/kg/min Can be met with a variety of intensi?es 30 min x 3 MET x 5x/wk = 450 MET. min/wk 20 min x 6 MET x 4x/wk = 480 MET. min/wk
Wannamethee S G et al. Circulation 2000;102:1358-1363 Greatest risk reduction is observed in least active individuals Risk reduction equal or exceeds risk reduction with statin therapy Copyright American Heart Association Screening for Exercise in the High- Risk PaNent Three stages Screening for Exercise 1. Self- guided assessment ParQ, AHA/ACSM Pre- parncipanon QuesNonnaire 2. CVD risk factor assessment 2 or more risk factors: consult w/physician prior to ininanng vigorous exercise High risk pt consult w/physician prior to ininanng an exercise program 3. Medical evaluanon Source: ACSM Guidelines for Exercise Tes?ng and Prescrip?on, 9 th Edi?on
CVD Risk Factors Source: ACSM Guidelines for Exercise Tes?ng and Prescrip?on, 9 th Edi?on Guidelines for Medical EvaluaNon Source: ACSM Guidelines for Exercise Tes?ng and Prescrip?on, 9 th Edi?on Supervision of Exercise Supervision High risk can be supervised by non- physician health care provider, if trained in clinical exercise tesnng physician should be immediately available Moderate risk - can be supervised by non- physician health care provider, if trained in clinical exercise tesnng Whether physician should be immediately available dependent upon local policies/circumstances, experience of lab staff Source: ACSM Guidelines for Exercise Tes?ng and Prescrip?on, 9 th Edi?on
Physical AcNvity and the Metabolic Syndrome Diabetes PrevenNon Program Goal: Compare pharmacotherapy and lifestyle effects on incidence of diabetes in at risk individuals 3234 subjects 1082 to placebo 1073 to mehormin 1079 to intensive lifestyle intervennon weight reducnon of at least 7 percent low- fat diet Increased physical acnvity (150 minutes per week of moderate intensity PA, such as brisk walking) The Diabetes Prevention Program Research Group: Reduction in the incidence of type 2 diabetes with lifestyle modification or metformin. N Engl J Med 346:393 403, 2002 Changes in Weight, Physical Fitness, Waist Circumference, and Glycated Hemoglobin Levels during 10 Years of Follow-up. The Look AHEAD Research Group. N Engl J Med 2013;369:145-154.
Aerobic, Resistance, or Both? From: Effects of Aerobic and Resistance Training on Hemoglobin A 1c Levels in Patients With Type 2 Diabetes! : A Randomized Controlled Trial! JAMA. 2010;304(20):2253-2262. doi:10.1001/jama.2010.1710" Figure Legend:! Monthly mean hemoglobin A 1c (HbA 1c) levels, derived from a mixed-linear model containing the covariates of age, sex, race/ ethnicity, diabetes duration, and baseline HbA 1c, are presented for group with the intention-to-treat analysis (n = 262) and the perprotocol analysis (n = 215). For the intention-to-treat model, the group (P =.01) and month (P <.001) effect were statistically significant. Error bars represent standard errors. " Copyright 2014 American Medical Association. Date of download: 3/5/2014" All rights reserved." Fitness vs. Fatness
Fitness Fatness and CVD Mortality in Men: ACLS Unfit Risk for Death Fit Reference Normal Weight Overweight Obese Wei M, et al. JAMA. 1999;282:1547-1553. Cardiorespiratory Fitness and Incident Type 2 Diabetes in 8,633 Healthy Men: ACLS Cases per 1,000 man-years Low Moderate Cardiorespiratory Fitness High Wei M, et al. Ann Intern Med. 1999;130:89-96. So, what is more clinically important Fitness or Fatness?
Sedentary Behavior and Metabolic Syndrome Australian Diabetes, Obesity, and Lifestyle Study (AusDiab) 11,000 Adults from Australia and Northern Territory Among adults without diabetes, self- reported sedentary behavior (e.g. TV Nme) Nme was posinvely associated with abnormal glucose metabolism and risk of metabolic syndrome AssociaNon is sustained aker adjusnng for leisure Nme Physical AcNvity Adjusted for age, sex, ethnicity, education, alcohol consumption, smoking, BMI, diabetes, heart disease and physical activity Dunstan, Diabetalogia, 2005 Dunstan, Diabetes Care, 2004 Bankoski, Diabetes Care, 2011 Being sedentary is disnnct from being inacnve Physically acjve meenng ACSM/AHA recommendanons ParNcipaNng in moderate intensity acnvines (biking, swimming, running) that expend 3 8 METs Physical inacjve lack of moderate to vigorous physical acnvity, as defined by ACSM/AHA SNll spend high propornon of day performing light intensity acnvines (standing, slow walking) that expend 1.6-2.9 METs Sedentary (LaJn sedere, to sit ) spending a high propornon of wakeful day engaged in behaviors that have level of energy expenditure barely above resnng energy expenditure (1.0 1.5 METs) silng, lying down, using the computer, watching TV, silng in a car Americans spend on average 7.7 hrs/day silng (54.9% of Nme)
The Biology of Sedentary Behavior Even light acnvity substannally increases muscular acnvity in large postural muscles of back, legs, and trunk Increases glucose, fany acid, and triglyceride uptake Standing Muscular inactivity High levels of silng Nme decrease HDL Zderic, J Apply Physiol, 2006 Hamilton, Ex Sci Sports Rev, 2004 Hamilton, Diabetes, 2007 Modifying Sedentary Behavior Decrease total sedentary Nme Take periodic breaks from sedentary Nme How oken? Lab studies show effects on HDL, glucose, and lipids occur within 4 hrs Breaking it up Healy, Diabetes Care, 2008
Mean (95% CI) plasma glucose, insulin, and triglyceride concentrations measured over a 9-h period during the prolonged sitting, physical activity, and regular-activity-break interventions measured in 70 healthy participants. Glucose AUC (mmol/l/9 h) 60 40 20 0 Sitting PA Breaks Insulin AUC (IU/L/9 h) 4000 3000 2000 1000 0 Sitting PA Breaks Triglcyceride AUC (mmol/l/9 h) Peddie M C et al. Am J Clin Nutr 2013;98:358-366 40 20 0 Sitting PA Breaks 2013 by American Society for Nutrition