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T2DM EXERCISE T2DM EXERCISE PROGRAMMES PROGRAMMES ((Specific NeedsSpecific Needs))

Agustín Meléndez-Ortega Ph.D.Agustín Meléndez-Ortega Ph.D.

INTRODUCTIONINTRODUCTION

Definition and prevalenceDefinition and prevalence T1DM - T2DM T1DM - T2DM Aims of the exercise programmeAims of the exercise programme Organizational preconditionsOrganizational preconditions Demands for qualification of instructorsDemands for qualification of instructors Evaluation measuresEvaluation measures Learning outcomesLearning outcomes

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DEFINITIONDEFINITIONandand

PREVALENCEPREVALENCE

Diabetes MellitusDiabetes Mellitus

Chronic illness (hyperglycemia)Chronic illness (hyperglycemia) Hyperglycemia: results from Hyperglycemia: results from

defects in insulin secretion, defects in insulin secretion, receptors, or bothreceptors, or both

Associated to obesity, Associated to obesity, hypertension, high cholesterol hypertension, high cholesterol & cv mortality& cv mortality

Inactivity (sedentarism) illnessInactivity (sedentarism) illness

Image: Medline PlusImage: Medline Plus

Glucose Transporter -Type 4 Glucose Transporter -Type 4 (GLUT4)(GLUT4)

Goodyear y Horton 2001Goodyear y Horton 2001

- Rate limiting step in glucose utilization

- Facilitated Diffusion

- GLUT4 major transporter

isoform

- Exercise and insulin are powerful stimulatorsGlycogen Glycolysis

Glucose transport in the Glucose transport in the presence of insulinpresence of insulin

GLUT4 translocation in the skeletal muscleGLUT4 translocation in the skeletal muscle

Goodyear y Horton 2001Goodyear y Horton 2001

Exercise and insulin action on the skeletal Exercise and insulin action on the skeletal musclemuscle

Goodyear y Horton 2001Goodyear y Horton 2001

PrevalencePrevalence

Source: International Diabetes Federation; MedMarket Diligence, LLC, report #D500, Source: International Diabetes Federation; MedMarket Diligence, LLC, report #D500, "Diabetes Management, Worldwide, 2005-2015: Products, Technologies and Markets in the "Diabetes Management, Worldwide, 2005-2015: Products, Technologies and Markets in the U.S., Europe, Japan & Rest of World."U.S., Europe, Japan & Rest of World."

European Prevalence of European Prevalence of DiabetesDiabetes

There are about There are about 50-60 million50-60 million people with people with diabetes in the European region, or about diabetes in the European region, or about 10.3% of men and 9.6% of women10.3% of men and 9.6% of women aged 25 aged 25 years and over.years and over.

Prevalence of diabetes is increasing among all Prevalence of diabetes is increasing among all ages in the European region (overweight and ages in the European region (overweight and obesity, unhealthy diet and physical inactivityobesity, unhealthy diet and physical inactivity).).

Source: OECD (2012), “Diabetes prevalence and incidence”, in Health at aSource: OECD (2012), “Diabetes prevalence and incidence”, in Health at aGlance: Europe 2012, OECD Publishing.Glance: Europe 2012, OECD Publishing.http://dx.doi.org/10.1787/9789264183896-17-enhttp://dx.doi.org/10.1787/9789264183896-17-en

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AIMSAIMSof theof the

EXERCISE PROGRAMMEEXERCISE PROGRAMME

Exercise Programme (DM1)Positive effects of training on insuline resistance

Strong evidence

Modetare evidence

Limited evidence

No evidence

A CB D

Pathogenesis

Physical fitness or strength

Symptoms specific to the diagnosis

Quality of life

Source: Pedersen BK and Saltin B; Scand J Med Sci Sports; 2006:16 (Suppl:1)

Exercise Programme (DM2)Positive effects of training on insulin resistance

Strong evidence

Moderate evidence

Limited evidence

No evidence

A CB D

Pathogenesis

Physical fitness or strength

Symptoms specific to the diagnosis

Quality of life

Source: Pedersen BK and Saltin B; Scand J Med Sci Sports; 2006:16 (Suppl:1)

Aims of the Exercise Aims of the Exercise ProgrammeProgramme

General for HealthGeneral for Health Physical FitnessPhysical Fitness Risk FactorsRisk Factors

SpecificSpecific Body CompositionBody Composition Short term ControlShort term Control Medium term controlMedium term control

0

1

2

3

4

5

6

7

8

9

10

Ris

k of

CVD

Mor

talit

y

18.5 < BMI <25.0 25.0 ≤ BMI <30.0 30.0 ≤ BMI < 35.0

Ref

eren

ce

*Adj. for age and examination year*Adj. for age and examination year

Church TS et al. Church TS et al. Arch Int MedArch Int Med 2005; 165:2114 2005; 165:2114

CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men Diabetes, 179 CVD Deaths

ORGANIZATIONAL ORGANIZATIONAL PRECONDITIONSPRECONDITIONS

Scenarios (Time with the disease) T2DM < 2 years T2DM 2-5 years T2DM > 5 years Elderly (> 65) T2DM

CV Fitness < pred. VO2 max > pred. VO2 max

Body composition > BMI 30 < BMI 30

Source: Modified from Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007.Source: Modified from Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007.

Scenario 1Scenario 1::Obese patients recently diagnosedObese patients recently diagnosed

Intense to moderate aerobic Intense to moderate aerobic exercise (Daily exercise exercise (Daily exercise preferable).preferable).

Combined with a caloric Combined with a caloric restriction to produce a weekly restriction to produce a weekly weight loss of ½ to 1 kilo.weight loss of ½ to 1 kilo.

At least 1 weekly session of At least 1 weekly session of strength training to avoid loss of strength training to avoid loss of muscle massmuscle mass..

Source: Modified from de Praet, SF y Van Loon, LJ. J. Appl Phys 103: 1113-1120, 2007.Source: Modified from de Praet, SF y Van Loon, LJ. J. Appl Phys 103: 1113-1120, 2007.

Image: Exercise Physiology: Wilmore y CostillImage: Exercise Physiology: Wilmore y Costill

Scenario 2Scenario 2::Patients who have had the condition Patients who have had the condition for some time and have been treated for some time and have been treated

with insulinwith insulin Bear in mind comorbidities.Bear in mind comorbidities. Programme intermittent exercises, Programme intermittent exercises,

relatively intense strength training relatively intense strength training exercises and aerobic-type exercisesexercises and aerobic-type exercises

Once an improvement in muscle Once an improvement in muscle strength and functional performance strength and functional performance has been achieved, progress to a more has been achieved, progress to a more generic intervention programme (with generic intervention programme (with more intense aerobic exercise)more intense aerobic exercise)

Fuente: Praet, SF y Van Loon, LJ; J. Appl Phys 103: 1113-1120, 2007.Fuente: Praet, SF y Van Loon, LJ; J. Appl Phys 103: 1113-1120, 2007.

Image: Image: Robert Newton. Edith Cowan UniversityRobert Newton. Edith Cowan University

Scenario 3Scenario 3::Elderly people Elderly people

recently diagnosed recently diagnosed with T2DMwith T2DM

Important: Strength training (To avoid or Important: Strength training (To avoid or reverse the loss of muscle mass).reverse the loss of muscle mass).

Co-intervention with dietCo-intervention with diet

Source: Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007. Source: Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007.

Image: Image: Robert Newton. Edith Cowan UniversityRobert Newton. Edith Cowan University

Scenario 4Scenario 4::Insulin resistant state with no Insulin resistant state with no

complicationscomplications

Glycemic control, cardiorespiratory fitness and Glycemic control, cardiorespiratory fitness and microvascular function can be improved with a microvascular function can be improved with a more vigorous programme [including strength more vigorous programme [including strength training and flexibility]training and flexibility]

Source: Praet, SF y Van Loon, LJ. J.; Appl Phys 103: 1113-1120, 2007.Source: Praet, SF y Van Loon, LJ. J.; Appl Phys 103: 1113-1120, 2007.

Images: Left. Dr. Robert Newton. Edith Cowan University; Right. Human Kinetics CatalogImages: Left. Dr. Robert Newton. Edith Cowan University; Right. Human Kinetics Catalog

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DEMANDS DEMANDS for for

QUALIFICATIONQUALIFICATION of the of the

INSTRUCTORSINSTRUCTORS

Demands for Qualification of the Demands for Qualification of the InstructorsInstructors

General Exercise Programmes (See Capacity General Exercise Programmes (See Capacity Building-Active Age)Building-Active Age)

Diabetic specific and risk factorsDiabetic specific and risk factors Management of hyper and hypoglycemiaManagement of hyper and hypoglycemia Avoidance of complication for comorbiditiesAvoidance of complication for comorbidities Adaptation for contraindications Adaptation for contraindications

Demands for Qualification of the Demands for Qualification of the InstructorsInstructors

ProgrammingProgrammingComplications (Comorbidities)Complications (Comorbidities)

Bear in mind that subjects are usually sedentary, Bear in mind that subjects are usually sedentary, with high blood pressure and cholesterol and with high blood pressure and cholesterol and overweight or obese, possible contraindications. overweight or obese, possible contraindications. ComorbiditiesComorbidities Physical FitnessPhysical Fitness Body composition Body composition TreatmentTreatment Orthopedic limitations (e.g. feet…),Orthopedic limitations (e.g. feet…),

ProgrammingProgramming

Retinopathy Retinopathy

HypertensionHypertension

Autonomous neuropathyAutonomous neuropathy

Peripheral NeuropathyPeripheral Neuropathy

NephropathyNephropathy

Source: B. N. Campaigne: Exercise and Diabetes Control. ACSM´s Resource Manual, 1998

Complications of DiabetesComplications of Diabetes(Comorbidities)(Comorbidities)

ComplicationsComplications

Source: B. N. Campaigne: Exercise and Diabetes Control. ACSM´s Resource Manual, 1998

Complications of DiabetesComplications of Diabetes(Comorbidities)(Comorbidities)

Proliferative retinopathyProliferative retinopathyMicroangiopathyMicroangiopathySevere neuropathySevere neuropathyNephropathyNephropathyEvidence of underlying CV diseaseEvidence of underlying CV disease

Bear in mind the absolute contraindications Bear in mind the absolute contraindications for exercisefor exercise

Lack of glycemic control (T1, >250 mg/dL y Lack of glycemic control (T1, >250 mg/dL y KK) (T2 >300 mg/dL)KK) (T2 >300 mg/dL)

Evaluation MeasuresEvaluation Measures

Pre and post stress test - (CV risk) & Pre and post stress test - (CV risk) & Classification Classification

Subject evaluationSubject evaluation Glucose response to exercise (programme)Glucose response to exercise (programme) Fitness evaluation (Blair)Fitness evaluation (Blair) Diabetes evolution (A1C)Diabetes evolution (A1C) Controls and glucose response to exerciseControls and glucose response to exercise

Programme evaluationProgramme evaluation AttendanceAttendance SatisfactionSatisfaction ResultsResults

Learning OutcomesLearning Outcomes

FOR THE SUBJECTFOR THE SUBJECTHow to improve blood glucose How to improve blood glucose

control with exercisecontrol with exerciseDecrement achieved in risk factorsDecrement achieved in risk factorsShort term responseShort term responseMedium term responseMedium term responseHow to act if complications ariseHow to act if complications arisePossible mechanism for different Possible mechanism for different

types of exercisetypes of exercise