The role of exercise in diabetes care

The role of exercise in diabetes care Eun-Jung Rhee Endocrinology and Metabolism, Kangbuk Samsung Diabetes and Vascular Center, Sungkyunkwan University School of Medicine

Contents Why do we exercise? Results of exercise monitoring - KSDC How to educate the patients 3 3

Contents Why do we exercise? Results of exercise monitoring - KSDC How to educate the patients 4 4

Acute (dynamic) and sustained (static) changes in adipose tissue both contribute to the overall response to exercise training or increased physical activity

The contracting muscle signal Justyna SZOSTAK et al. Clinc Sci 21:91-106, 2011

Acute exercise induces GLUT4 translocation in skeletal muscle in normal and T2DM patients In 5 normal subjects and 5 T2DM patients, translocation of GLUT4 to the plasma membrane of skeletal muscle (vastus lateralis) assessed Kennedy JW et al. Diabetes, 1999

Exercise increases sensitivity of glucose uptake to insulin in human muscle Wojtaszewski et al. J Appl Physiol 93:384-392, 2002

Effects of physical exercise on insulin secretion Acute exercise Almeida FN et al. Islets, 2012 Beaudry JL et al. Diabetes Metab Res Rev, 2012

REF, T2D physically active, treated and controlled * compared to referent p > 0.05 Brown RE, et al. J Diabetes Complications. 2014 May-Jun;28(3):311-5. Adults with T2D who are physically active, pharmacologically treated, and obtain glycemic control may attain similar mortality risk as normoglycemic adults.

Physical Activity To improve glycemic control, assist with weight maintenance, and reduce risk of CVD, at least 150 min/wk of moderate-to-vigorous intensity aerobic physical activity per week, spread over at least 3 days/w, no more than 2 consecutive days without activities. Shorter durations (minimum 75 min/w) of vigorous interval training for younger and more fit individuals Should engage in 2-3 sessions /W of resistance exercise on nonconsecutive days; with each session consisting of at least one set of five or more different resistance exercises involving large muscle Prolonged sitting should be interrupted every 30 minuets for blood glucose benefit, in patients with T2DM Flexibility training and balance training recommended 2-3 times/w for older adults with diabetes. Yoga and tai chi may be included based on personal preferences ADA Standards of Medical Care in Diabetes, 2017 2015 당뇨병진료지침

Endurance type exercise An acute bout of endurance type exercise improves insulin sensitivity for a period up to 48 h. Long-term weight loss and weight control Feasibility in elderly patients with T2DM Feasibility in T2DM with co-morbidities Delvin et al, Diabetes, 1987 Mikines et al, AJP, 1988 Perseghin et al, NEJM, 1996

Resistance type exercise Improved glucose disposal Glycogen storage capacity GLUT-4 content Glycemic control (HbA1c: -1.1%) Insulin sensitivity Oral glucose tolerance Cardiovascular risk profile (HDL, LDL, BP) Body composition Castaneda et al, 2002;Dunstan et al, 1998, 2002; Ishii et al, 1998, Cauza et al, 2005; Willey et al, 2003

What type of exercise? 15 IGT, 15 T2DM treated with insulin & 15 T2DM treated with oral glucose-lowering medication (OGLM) van Dijk et al. Diabetologia 55:1273, 2012

24-h glycemic profiles No difference between the two groups

Effects of Aerobic and Resistance Training on HbA1c levels in patients with T2DM 262 sedentary men & women with T2DM (mean age 55.8 years) 9-month Conclusions: exercise Among program: patients control, with aerobic type training 2 diabetes only, resistance mellitus, training a combination only, & a combination of aerobic and of resistance both training compared with the non-exercise control group improved HbA1c levels. This was not achieved by aerobic or resistance training alone Church et al. JAMA 304:2253, 2010

Is daily exercise required to optimize glycemic control? 30 T2DM pts; randomized crossover study van Dijk et al. Diabetes Care 35:948, 2012

Prevalence of hyperglycemia No differences between the groups with daily exercise vs. every other day exercise group van Dijk et al. Diabetes Care 35:948, 2012

Effect of moderate-intensity exercise vs. activities of daily living on 24-hr blood glucose homeostasis 20 males with T2DM in a randomized 3-day cross-over study van Dijk JW et al. Diabetes Care, 2016

Effect of moderate-intensity exercise vs. activities of daily living on 24-hr blood glucose homeostasis 20 males with T2DM in a randomized 3-day cross-over study Conclusions: When matched for total duration, moderate-intensity endurance-type exercise represents a more effective strategy to improve daily blood glucose homeostasis than repeated bouts of activity of daily living van Dijk JW et al. Diabetes Care, 2016

Benefits for T2DM of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities In 24 inactive overweight/obese adults with T2DM SIT LW SRA 21 21 Dempsey PC et al. Diabetes Care,2016

Yoga and glycemic control in patients with T2DM: meta-analysis 12 RCTs analyzed Effect of yoga on fasting blood glucose 22 22 Cui J et al. JDI, 2017

Yoga and glycemic control in patients with T2DM: meta-analysis 12 RCTs analyzed Effect of yoga on HbA1c (a), and postprandial glucose (b) 23 23 Cui J et al. J Diabetes Invest, 2017

Cautions according to complications Retinopathy : PDR or severe NPDR vigorous aerobic or resistance exercise CIx Peripheral neuropathy : Thorough assessment needed; moderate walking not CIx Autonomic neuropathy : increased risk of exercise-induced injury or adverse events; should undergo cardiac investigation before beginning physical activity Diabetic kidney disease: No evidence of vigorous intensity exercise increase the rate of progression of DKD, no need for specific exercise restrictions for DKD patients 24 24 ADA Standards of Medical Care in Diabetes, 2017 2015 당뇨병진료지침

Exercise in patients with diabetes Exercise strongly reduce the prevalence of hyperglycemia throughout the day If well-controlled patients are active, they will have similar risk for CVD and mortality to normoglycemic patients Resistance and endurance type exercise are equally effective in improving daily blood glucose homeostasis When total work is being matched, daily exercise does not further improve glycemic control, when compared to exercise performed every other day When matched for duration, exercise is more effective than more habitual physical activity to improve glycemic control 25 25

Contents Why do we exercise? Results of exercise monitoring - KSDC How to educate the patients 26 26

Lifecorder (accelerometer) Has a sensor of acceleration and records the acceleration of vibration of up and down activity of body every 4 sec 7.5 x 4.2 x 2.9 cm/ 45g

Lifecorder (accelerometer) Results

Lifecorder (accelerometer)

Exercise eduction In 14 prediabetes patients Prediabetes education with nutrition education for weight control Lifecorder for 3 months (followed up every month) Experimental group (7) : Analysis for PA and set up for target goal Control group (7) : Analysis for PA and general education

Comparison of the metabolic parameters after 3 months of exercise education 1) FBS and HbA1C

Comparison of the metabolic parameters after 3 months of exercise education 2)Total-C, TG, HDL-C

Comparison of the metabolic parameters after 3 months of exercise education 3)BMI, Waist circumference

Comparison of the metabolic parameters after 3 months of exercise education 4)T.A.T, T.S

Contents Why do we exercise? Results of exercise monitoring - KSDC How to educate the patients 41 41

Step 1: Increasing physical activity!

Any movement (or force) Physical activity exerted with skeletal muscle that leads to an increase in energy expenditure above rest Exercise Subcomponent of physical activity that is planned, repetitive or structured

My work is laborious; this is exercise Household chores are very laborious; this is exercise

Move and move!! 120kcal /day = 5kg/year dish washer-> self wash Elevator -> stairs Car -> walk Elevator Stairs (Lanningham et al 2003)

Calori loss in each activity Sitting Staning Chewing gum Moving Climbing stairs Walking 1.6km/h Walking 3.2km/h Walking 4.8km/h (Levine 2004)

Change the life style! 1. Walk to places in short distance 2. Walk as fast as possible 3. Use stairs instead of escalator 4. Stretching as often as possible 5. Park your car as far as possible from the desination 6. Do not use remote control when changing the TV channel

Step 2 : Regular exercise

Assess the cardiorespiratory function 1, consult your doctor before starting exercise Question Have you been told to consult your doctor before starting exercise due to your heart problem? Have you felt chest pain when exercising? Have you felt chest pain when resting during the last few months? Have you lost your balance due to fainting or dizziness? Do you have any problem in bone or joint? Are you taking any medications for hypertension or heart disease? Do you have any reason for being unable to exercise? Yes or no American Sports Medicine

Need for exercise tolerance test Exercise tolerance test Age>35 years Known or suspicious CAD Disease duration of Type 1 diabetes 15 years Disease duration of Type 2 diabetes 10 years Microvascular, macrovascular disease Autonomic neuropathy

Planning exercise Choose the type of exercise (Disease, preference, etc..) Consume 700kcal~2000kcal of calories every week At least 3 times every week

What kind of exercise?

How long? 150 minutes per week ( 700kcal) 3 times/ wk 50 minutes 4 times/ wk 40 minutes 5 times/ wk 30 minutes Consider individual fitness! At least 10 minutes * 3 times or 30 minutes at once

Intensity [(Maximal HR-Resting HR) * 0.5~0.75] +Resting HR Maximal HR = 220-Age Resting HR = HR / minute Cannot be used in patients with automic neuropathy, CVD

Intensity Effects minimal Talking to each other possible while walking Danger for trauma, aggravation of disease Intensity Very light Light Slightly difficult Difficult Very difficult

Before and after exercise Stretching For 5-10 minutes Sustain for 8~10 sec, 3 sets Maintain the respitation

Resistance exercise Shoulder, waist, chest, abdomen and leg From large muscle to small muscle (chest - >arm) 8~12 times for 2~3 sets Resting time between the sets for 30 sec~1 min Sustaining respiration is important

Arm muscle exercise

Shoulder muscle exercise

Abdomen exercise

Thigh muscle exercise

Calf muscle exercise

Summary Exercise is an important component of diabetes education For patients with diabetes, exercise is not optional, but essential part of treatment Educators should be familiar with exercise themselves Any exercise that fits the patient is the best exercise for him or her Being repetitive and regular is important than what exercise you are doing Tell the patient they have to exercise to improve their health, not just for glucose control 63 63

For long and healthy life of our patients.. 64 64