Exercise & Diabetes Mellitus by malj

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									Exercise & Diabetes Mellitus
Abdulrahman Mohammed AL-Howikan
Director of Cardiopulmonary Exercise Testing And pulmonary function test Lab, Medicine dep., College of Medicine King kalied university hospital
Diabetes Educator Course, KA Med City, April 2007
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Definitions
Physical Activity
Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state.

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Physical Fitness
A set of attributes that people have or achieve, which relates to the ability to perform physical activity.
Caspersen, et al., Public health Rep,1985
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Definitions
Metabolic Equivalent (MET)

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The amount of energy expended during exercise relative to the energy expenditure during rest.
Energy expenditure during rest = 1 MET = 3.5 ml of O2 / kg. min = 1 kcal / kg. hr
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Classification of Exercise
Aerobic exercise:
Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc…

Strength (Resistance) exercise:
Weight training with free weight, machine, elastic rope, calisthenics, etc…

Flexibility exercise:
Stretching exercise.
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Physical Activity Intensity in MET
Light: Less than 3 MET Moderate: 3 – 6 MET Vigorous: Above 6 MET

CDC, 1996

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Moderate & Vigorous Intensity
Physical Activities

Moderate:
Brisk walking, Recreational swimming, Volleyball, Slow aerobics, Moderate cycling Gardening, Tennis-double, Badminton etc..

Vigorous:
Jogging, Running, Tennis-single, Basketball, Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Soccer, etc
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What is the Amount of Physical Activity that Promotes Health?

   

Moderate Intensity Physical Activity. Energy Expenditure = 3 - 6 MET That is: ≥ 30 min/day, ≥ 5 days/week. 150 min. per week.
ACSM, 2000; CDC, 1996

 ≥ 1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000

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Health-Related Dimensions of Physical Activity

‫أبعاد النشاط البدني المعزز للصحة‬
.)Caloric Expenditure( ‫الطاقت المصروفت‬
.)Aerobic Intensity( ‫األنشطت الهىائيت المرتفعت الشدة‬ .)Muscular Strength( ‫القىة العضليت‬
.)Flexibility (

‫المرونت‬

‫األنشطت البدنيت التي يتم فيها حمل الجسم‬
.)Weight-bearing

• • • • •
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physical activity(

ACSM, 2000 Caspersen, et al., 1998

Exercise & Diabetes
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Can Exercise Prevent or Delay Diabetes ?
Evidences from Randomized Clinical Trials
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Exercise in the Prevention of Diabetes
Participants are either normal or have + GTT
Malmo Study Da Qing, China The Nurse’s Health Study Finnish
Experimental Study

Sweden 260 males

(6 yrs)
China USA Finland

Eriksson & Lindgarde, Diabetologia, 19991 Pan, et al, Diabetes Care, 1997 Hu, et al., JAMA, 1999 Tuomilehto, et al., N Engl J Med, 2001
Diabetes Prev. Program Research Group,

577 males & Females (6 yrs) 70,000 Nurses (8 yrs) 523 males & Females (4 yrs)
3234 males & Females (3 yrs)

USA Diabetes Prevention Study

N Engl J Med, 2002
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Exercise in the Prevention of diabetes
Summary of the Results

Moderate Physical Activity Performed Regularly for 120 – 200 min. per week Reduces the Incidence of Diabetes in People Predisposed to Diabetes.

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Exercise in the
Management of

Diabetes
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Exercise & Type 1 Diabetes
Improves physical fitness. Increases self confidence. Improves CV function & CHD risk profile. It has no direct effect on glucose control. Proper timing of Exercise & Insulin. Avoid strenuous exercise before bed time.

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Exercise & Type 2 Diabetes
Improves physical fitness & reduces fat %.
Improves CV function & CHD risk profile.

Increases self confidence. Improves glucose control:

 Improving insulin sensitivity.  Increasing Glu T4 (glucose transporters).

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Response to 100 g of glucose in mild Type 2 Diabetics
12 months of Training
20

Plasma Glucose (mmol/l)

15 10 5
Before After

0 0 30 60 90 120 150 180

Time (min)
Holloszy, et al. Acta Medica Scand 1986, 711: 55-65 KSU

Response to 100 g of glucose in mild Type 2 Diabetics
12 months of Training
1600

Plasma Insulin (pmol/l)

1200 800 400 Before 0 0 30 60 90 120 150 180 After

Time (min)
Holloszy, et al. Acta Medica Scand 1986, 711: 55-65 KSU

Exercise Prescription for Diabetic
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Exercise Prescription for Diabetic

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Aerobic activity for 30 min. extended (gradually) to 60 min. every day or most days/week. HR during activity should be gradually increased to reach 60 – 70% of HR max. Exercise session should include 5-10 min. of warm-up and a 5 min of cool-down. Exercise must involve most major muscles in both lower and upper parts of the body.
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Exercise Prescription for Diabetic
Exercise must be regular. Benefits are diminished after 1 -2 weeks of stopping .

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Moderate intensity weight training program is recommended to maintain muscle strength ( 8-12 repetitions 2 times /week). For those with feet problems, avoid running. Alternate between walking, swimming, and cycling.

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Exercise Prescription for Diabetic

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Use proper shoes, with silica gel or air-filled soles, and always keep feet dry.

When using insulin, avoid exercise if glucose levels below 100 mg/dl or above 250 mg/dl.
Do not inject insulin into a body part that is expected to be used during exercise.

Avoid dehydration by keeping your body always hydrated.
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Graded Exercise Testing for Diabetic

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It is recommended before any moderate to high intensity exercise, especially if:

 Age is > 35 yrs.
    Type 2 diabetes for > 10 yrs duration. Type 1 diabetes for > 15 yrs duration. Presence of any CHD risk factors. Presence of microvascular disease
(retinopathy, nephropathy).

 Presence of peripheral vascular disease.

ADA Position Statement, Diabetes Care, 2002

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Exercise Prescription for Special Cases
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Diabetic with Peripheral Neuropathy
Peripheral neuropathy may results in loss of sensation in the feet. Repetitive exercise on insensitive feet can lead to ulceration & fractures.

Limit weight-bearing exercise (Treadmill,
Prolonged walking, Jogging, Step exercise, etc..)

Alternative exercises are: Swimming,
Bicycling, Arm exercise, Chair exercise, etc..

Use proper shoes, and always monitor the feet.
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Diabetic with Autonomic Neuropathy
This condition may limit exercise capacity & increase the risk of CV event during exercise.

Hypotension and hypertension are more likely to develop after vigorous exercise. Those patients may have difficulty with thermoregulation:

 Avoid exercise in hot or cold environments.  encourage adequate hydration.
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Hypoglycemia during or after Exercise
It will most likely occur if the patient:
  



Takes insulin or diabetes pill. Skips a meal. Exercises for a long time. Exercises strenuously.

If it occurs, what can be done?

 

Patient must eat a snack before exercise, or. Adjusts the medication dose. Remember: Patient should always carry a source of CHO with him ( An apple or orange juice, or a piece of
fruit).
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Energy Expenditure during Physical Activity!
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Energy Cost of Physical Activity
(kilocalorie/kg. min)

Activity
Brisk walking Running (7.5 min per km) Running (5 min per km) Swimming Rope skipping (70/min) Rope skipping (80/min) Badminton Tennis Squash Basketball
McArdle, et., 1991

Calorei
0.07 0.13 0.208 0.162 0.162 0.165 0.097 0.109 0.212 0.138

Energy Cost of Physical Activity
(MET)

Activity
Walking (slow) Walking (Brisk) Running (7.5 min per km) Swimming Rope skipping (slow) Weight training Badminton Tennis (single) Squash Basketball
Ainsworth, et., 2000

MET
2.5 4 8 6 8 6 4.5 8 12 8

How to Calculate Energy Expenditure during Brisk Walking!
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Energy Expenditure during Brisk Walking

= 0.07 k. calorie per kg of body weight /
min. An Example:

a person weighing 76 kg would expend:
0.07 X 76 = 5.3 k. calorie per min.

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Energy Expenditure during Brisk Walking
 If he has to expend 1200 k. calories per week. How much time he should walk per week?

 1200 / 5.3 = 226.4 min. = 45 min / 5 days per week, or = 57 min / 4 days per week.

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Case Studies
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Case Study 1

(Q)

An obese sedentary women, her age = 55 yrs, weight = 80 kg, height = 152 cm. Has type 2 diabetes for 6 years, and BP under control with medication. Otherwise she is OK. Prescribe diet and physical activity to reduce her weight as well as to control her diabetes and hypertension, targeting energy expenditure with exercise of 1600 K. calories per week? Assuming a target body wt. of 60 kg, what is her daily energy needs?
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Case Study 1

(A)

BMI = 80/ (1.52 * 1.52) = 34.6 kg/m2 Walking: 0.07 K. calorie/kg. min. Energy cost of walking = 80 * 0.07 = 5.6 k cal. min. Time needed to expend 1600 k. cal. Per week = 1600/ 5.6 = 285.7 minutes;
285.7/5 days = 57.1 min.
OR approx. 1 hour a day for 5 days per week

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