James A. Stone - Diabetes Update€¦ · Umpierre (2011) Physical Activity Advice Only or Structured Exercise Training and Association with HBA1c Levels in Type 2 Diabetes JAMA 305

James A. Stone

BPHE, BA, MSc, MD, PhD, FRCPC, FAACVPR, FACC Clinical Professor of Medicine

University of Calgary

How Should We Write an Exercise Prescription!

• Background - CDA!• The Benefits of Exercise!

• In Diabetes!• The Principles of Exercise

Prescription!• In Diabetes – Special Considerations!

• Summary!


• Background - CDA!•  The Benefits of Exercise!

•  In Diabetes!•  The Principles of Exercise Prescription!

•  In Diabetes – Special Considerations!•  Summary!


Canadian Diabetes Association Clinical Practice Guidelines Physical Activity and Diabetes

Chapter 10 Ronald J Sigal, Marni J Armstrong, Pam Colby, Glen P Kenny, Ronald C Plotnikoff, Sonja M Reichert, Michael C Riddell

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association

Physical Activity Checklist

ü DO a minimum of 150 minutes of moderate-to

vigorous-intensity aerobic exercise per week

ü  INCLUDE resistance exercise ≥ 2 times a week

ü SET physical activity goals and INVOLVE a multi-

disciplinary team

ü ASSESS patient’s health before prescribing an

exercise regimen

2013


Physical Activity: Bridging the Gap

Problems Solutions Lack of knowledge of resources

Increase awareness among health care professionals of community resources

Time constraints during physician-patient encounter

Involve a multi-disciplinary team of Physical Therapists, Diabetes Educators and Case Workers who can help motivate patients

Pre-existing or suspected heart disease

If patient wishes to take on activity more vigorous than walking, evaluate with a history and physical, resting ECG and possibly exercise ECG stress test.


Know your Community Resources and

Advertise Them

Speak to your patients about community

resources:

Community pools, gyms, safe walking

trails, weight loss smart phone apps etc.

•  Background - CDA!

• The Benefits of Exercise!• In Diabetes!

•  The Principles of Exercise Prescription!•  In Diabetes – Special Considerations!

•  Summary!


How Should We Write an Exercise Prescription!CV and Health Benefits of Exercise!


• Physical Activity and Mortality !

199 265 men and 216 910 women In Taiwan 1996-2008, FU 8.05 years

Lancet 2011; 378: 1244–53


How Should We Write an Exercise Prescription!U-Curve and Mortality with Exercise!

•  The Benefits of Exercise!

• In Diabetes!•  The Principles of Exercise Prescription!•  In Diabetes – Special Considerations!•  Summary!


Church, Blair et al. Arch Intern Med (2005)165(18):2114-20

0

1

2

3

4

5

6

Rel

ativ

e R

isk

(kar

diov

ascu

lar M

orta

lity)

METS

BMI < 25 kg/m2 BMI 25-30 kg/m2 BMI ≥ 30 kg/m2

n= 2,316 male Diabetics Age = ∅ 50 y BMI = 18.5-34.9 kg/m²

BMI, Fitness, and Mortality in Type 2 Diabetes


Di Loreto et al. Diabetes Care (2005)28:1295-1302

Walking and cardiovascular risk factors

•  179 Type 2 Diabetics, 62 y •  walking program •  non-randomized •  2 years FU


Look AHEAD – clinical endpoints

NEJM (2013)369:145-54 Composite endpoint: CAD, nf AMI, nf stroke, Hospitalisation for Angina


NEJM (2013)369:145-54

Look AHEAD – Fitness


Umpierre (2011) Physical Activity Advice Only or Structured Exercise Training and Association with HBA1c Levels in Type 2 Diabetes JAMA 305 (17): 1790-1799

•  Meta-analysis –  endurance +/- resistance

–  47 RCTs –  8,538 patients

Training Δ HbA1c

endurance -0.73 (-1.06 -0.40)

resistance -0.57 (-1.14 -0.01)

combination -0.51 (-0.79 -0.23)

endurance

resistance

combination

HbA1c-changes, % (95% KI)



•  The Benefits of Exercise!•  In Diabetes!

• The Principles of Exercise Prescription!• Be FITT SMART!

•  In Diabetes – Special Considerations!•  Summary!


Pre-exercise Assessment

•  Assess for conditions that can predispose to injury before prescribing an exercise regimen:

–  Neuropathy (autonomic and peripheral)

–  Retinopathy

–  Coronary artery disease – resting ECG +/- exercise stress test (see CPG Chapter 23)

–  Peripheral arterial disease


www.guidelines.diabetes.ca

• FITT!


• SMART!



Interval training

Emil Zátopek

Gold London 1948 10,000 m Silver London 1948 5000 m Gold Helsinki 1952 5000 m Gold Helsinki 1952 10,000 m Gold Helsinki 1952 Marathon




•  The Benefits of Exercise!•  In Diabetes!•  The Principles of Exercise Prescription!•  In Diabetes – Special Considerations!

• Summary!



Recommendation 1

1.  People with diabetes should accumulate a minimum of 150 minutes of moderate to vigorous intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise [Grade B, Level 2, for

T2DM; Grade C, Level 3 for T1DM]


Recommendation 2

2.  People with diabetes (including elderly people) should perform resistance exercise at least twice a week, and preferably 3 times per week [Grade B, Level

2] in addition to aerobic exercise [Grade B, Level 2]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, level 3]


Recommendations 3 and 4 3.  People with diabetes should set specific physical

activity goals, anticipate likely barriers to physical activity (e.g. weather, competing commitments), develop strategies to overcome these barriers [Grade B,

Level 2], and keep records of their physical activity [Grade B, Level 2]

4.   Structured exercise programs supervised by qualified trainers should be implemented when feasible for people with type 2 diabetes to improve glycemic control, CVD risk factors, and physical fitness [Grade B, Level 2]

2013

2013


Recommendation 5

5.  People with diabetes with possible cardiovascular disease or microvascular complications of diabetes, who wish to undertake exercise that is substantially more vigorous than brisk walking, should have medical evaluation for conditions that might increase exercise-associated risk. The evaluation would include history, physical examination (including fundoscopic exam, foot exam, and neuropathy screening), resting ECG, and, possibly, exercise ECG stress testing [Grade D, consensus]

2013


CDA Clinical Practice Guidelines

http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients

• Patient Prescription Problems!


Documents

James A. Stone - Diabetes Update€¦ · Umpierre (2011) Physical Activity Advice Only or Structured Exercise Training and Association with HBA1c Levels in Type 2 Diabetes JAMA 305