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Exercise training in diabetes
Prof. dr. Dominique Hansen
Obesity epidemic
Obesity epidemic
Prevalence of obesity and severe obesity 2008–30 in USA
Obesity epidemic
Diabetes epidemic
Diabetes epidemic
Diabetes epidemic
Diabetes epidemic
European Opinion Research Group: Eurobarometer Report 2014
Exercise: why?
EXERCISE TRAINING =
INVESTMENT IN MORE AND BETTER TIME
Exercise: why?
Exercise: why?
Exercise: why?
Prevention of type 2 diabetes– 3234 glucose-intolerant subjects
Knowler et al. N Engl J Med 2002; 346: 393
Exercise in type 2 diabetes: why?
Daily metformin intake = -33% T2DM incidence
Change in lifestyle = -58% T2DM incidence
Prevention of type 2 diabetes
Through exercise training only?
37-49% risk reduction
Laaksonen DE, et al. Diabetes 2005; 54: 158-65
Exercise in type 2 diabetes: why?
• In 1982 it was found how blood glucose content could decrease as result of exercise
– Elevation of skeletal muscle insulin sensitivity– Richter EA, et al. J Clin Invest 1982; 69: 785-93– Richter EA, et al. Am J Physiol 1984; 246: E476-82
– Elevation of skeletal muscle glucose uptake…but also by a non-insulin dependent pathway
– Garetto LP, et al. Am J Physiol 1984; 246: E471-5
– Glucose utilisation could increase 20-fold as result of exercise
Exercise in type 2 diabetes: why?
Praet et al. Clin Sci 2006; 111: 119
13.30h hyperglycemic
0.4h hyperglycemic
Exercise in type 2 diabetes: why?
Praet et al. Med Sci Sports Exerc 2006; 38: 2037
Exercise in type 2 diabetes: why?
Exercise in type 2 diabetes: why?
Qiu S, et al. PLoS One. 2014 Oct 17;9(10):e109767
Exercise in type 2 diabetes: why?Umpierre D, et al. JAMA 2011; 305: 1790-99
Exercise in type 2 diabetes: why?
Umpierre D, et al. Diabetologia 2013; 56: 242-51
• Long-term exercise training in type 2 diabetes patients also positively affects:
– Quality of life– Physical fitness– Inflammatory markers – Cardiovascular disease risk factors
• Blood pressure, waist circumference, lipid profile
Exercise in type 2 diabetes: why?
Fear of exerciseNo exercise
Lowering in endurance capacity
Increase in fat mass
Worsening in CVD risk factors
Worse glycemic control
Further decrease in motivation to exercise
Further worsening in fat mass, exercise tolerance,CVD risk factors and glycemic control
Exercise in type 1 diabetes: why?
Exercise in type 1 diabetes: why?
Exercise physiology in obesity
Can be significantly different!
=
Exercise physiology in obesity
Tanner CJ, et al. Am J Physiol 2002; 282: E1191
Muscle fibre type composition
Exercise physiology in obesity
Body composition
Biolo G, et al. Clin Nutr 2014; 33; 737
Exercise physiology in obesity
Hormonal disturbances
Mittendorfer et al. Am J Physiol 2004
Goodpaster B, et al. Obes Res 2002; 10: 575
Vettor R, et al. Acta Diabetol 1997; 34: 61
Cedric MoroAdapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA
Exercise physiology in obesity
Suppressed lipolysis
Exercise physiology in obesity
Mittendorfer B, et al. Am J Physiol 2004; 286: E354
Adapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USAGondoni et al. Nutr Metab Cardiovasc Dis 2008
Exercise physiology in obesity
Cardiovascular disturbances
Exercise physiology in obesity
Cardiovascular disturbances
Salvadori A, et al. J Clin Basic Cardiol 1999; 2: 229
Ardevol A, et al. Eur J Physiol 1998; 435: 495
Exercise physiology in obesity
Cardiovascular disturbances
Exercise physiology in obesity
Ventilatory abnormalities
Satiago Lorenzo and Tony BabbAdapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA
Exercise physiology in obesity
Ventilatory abnormalities
Satiago Lorenzo and Tony BabbAdapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA
Could lower PaO2 during exercise
Disturbed muscle function
Muscle overload during walking/running
Increased RPE Borg especially during weight-baring exercises
Exercise physiology in obesity
Disturbed muscle function
Lowered fat oxidation capacity
Exercise physiology in obesity
Percentage of plasma free fatty acid (FFA) uptake oxidized during basal and exercise (50% maximum O2 consumption). *Significantly decreased in extremely obese and extremely obese subjects after weight reduction (weight-reduced) compared with
lean (P < 0.05).
Houmard J A Am J Physiol Regul Integr Comp Physiol 2008;294:R1111-R1116
Greater likelihood for development of orthopedic limitations
(knee) osteo artritis Plantar heel pain (plantar fasciitis) Carpal tunnel syndrome Rotator cuff tendinitis Low back pain
Exercise physiology in obesity
Type 2 diabetes patients show different physiological responses to exercise as
compared to healthy individuals
Type 2 diabetes patients are often overweight/obese, so typical anomalies in
exercise response which occur in the obese may be expected
Exercise physiology in type 2 diabetes
Exercise physiology in type 2 diabetes
Substrate selection is altered
Boon et al. Diabetologia 2007; 50: 103-12
Whole-body substrate source utilisation at rest (a) and during exercise (b) and post-exercise recovery (c).
Black, plasma NEFA; White, muscle and lipoprotein-derived triacylglycerol; Grey, carbohydrate in a and c, plasma glucose in b; hatching (b), muscle glycogen.
*Substrate source oxidation significantly different from control group (p<0.05) †total fat oxidation significantly different from control group (p<0.05)
Exercise interventions in type 2 diabetes
Exercise interventions in type 2 diabetes
How to prescribe exercise?
Adapt the exercise modalities! Exercise intensity Session duration Exercise frequency Program duration Addition of strength-training
Exercise intensity
Van Loon LJ, et al. J Physiol 2001; 536: 295
Exercise intensity
0123456789
baseline 2 months 6 months
Hb
A1c
(%
)
high-intensity
low -intensity
Hansen D, et al. Diabetologia 2008: 52: 1789-97
Exercise intensity
Umpierre D, et al. Diabetologia 2013; 56: 242-51
Mitranun W, et al. Scand J Med Sci Sport 2013; e-pub ahead of print
Exercise intensity
Session duration/volume
Assumption
Longer exercise sessions = greater effect
Greater decrease in plasma glucose levels in T2DM patients when cycling for 40 minutes at 70% VO2peak compared with 40 minutes at 50% VO2peak
Sriwijitkamol A, et al. Diabetes 2007; 56: 836-48
Program duration
International guidelines
Minimal 2 months in order to detect clinical benefits
Elevated physical activity should be sustained after supervised program completion
Program duration
Hansen D, et al. Sports Med 2010: 40: 921
HbA1c
months
Cessation of exercise training
Program duration
Exercise frequency
International guidelines
3 to 5 d/week At start of programme: 3 days After 4-6 months of exercise training: increase
training frequency
On a regular base!
days
Insulin sensitivity
Insulin sensitivity
Exercise frequency
Umpierre D, et al. Diabetologia 2013; 56: 242-51
Exercise frequency
Addition of strength exercises
International guidelines
Strength training exercises should be added:
10-15 reps, 3 series, 65-70% 1RM
Cauza et al. Arch Phys Med Rehabil 2005; 86: 1527
Addition of strength exercises
Cauza et al. Arch Phys Med Rehabil 2005; 86: 1527
Addition of strength exercises
Addition of strength exercises
Hansen D, et al. Sports Med 2010: 40: 921
Exercise in type 1 diabetes: how?
Exercise in type 1 diabetes: how?
Increased synthesis of epinephrine and growth hormone
Increased glucose release by liver
Increase the medical safety of intervention in following conditions:
• Peripheral neuropathy and/or delayed wound healing = be alert to wounds and/or peripheral sensation disturbances
• Autonomic neuropathy = be alert to deregulated blood pressure
• Cardiovascular disease = rule out coronary and/or peripheral vascular disease
• Retinopathy = no high-intensity exercises
• Nephropathy = avoid high blood pressures
ACSM & ADA. Med Sci Sports Exerc 2010; 42: 2282-303
How to maximize medical safety
How to maximize medical safety
• Orthopedic screening
– Diabetic hand syndrome
– Dupuytren contracture
– Trigger finger
– Diffuse idiopathic skeletal hyperostosis
– Charcot foot
How to maximize medical safety
• Check feet
– Shoes: worn out or too narrow?
– Feet: dermatologic risk factors
Glycemic control
• Start training session• Glucose <75 mg/dl: consume monosaccharides• Glucose <100 mg/dl: be alert for hypoglycemia• Glucose >300 mg/dl: rule out keto-acidosis, no high-intensity
exercise
• Risk factors for hypoglycemia during exercise• Prolonged (>60 min), and/or intense exercise• Exercise in fasting condition?• Medication: sulfonyloreas, meglitinide, exogeneous insulin
therapy
• During follow-up• Regularly assess blood glucose content• Always carry monosacharides with you• Exercise in group
ACSM & ADA. Med Sci Sports Exerc 2010; 42: 2282-303
How to maximize medical safety
How to maximize medical safety
• Check prescribed medication
– Cardioprotective drugs
• Diuretics– Dehydration and electrolyte imbalances when dosed too high
• Beta-blockers– Lowering in exercise HR– Lowers sensation of hypoglycemia
• Lipid-lowering medication– Statins could lead to myopathies
How to maximize medical safety
Hansen D, et al. Phys Ther 2013; 93: 597-610
KineCoach project
• Prevalence of T2DM is rapidly rising• T2DM is associated with many co-morbidities• Exercise intervention is highly effective• GP’s, cardiologists and endocrinologists often
promote a healthy lifestyle to their patients• But where can these patients follow medically
safe and clinically effective exercise interventions?
KineCoach project
Hansen D, et al. Phys Ther 2013; 93: 597-610
KineCoach project
Hansen D, et al. Vlaams Tijdschr Diabetol 2013; 1: 10-12
KineCoach project
Hansen D, et al. Phys Ther 2013; 93: 597-610
KineCoach project
Hansen D, et al. Phys Ther 2013; 93: 597-610
KineCoach project
Hansen D, et al. Phys Ther 2013; 93: 597-610
Contact: [email protected]
