Transcript 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.

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
1
Physical Activity
Any bodily movement produced by the
skeletal muscles resulting in energy
expenditure above resting state.
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
2
Metabolic Equivalent (MET)
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?
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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( ‫الطاقة المصروفة‬
.)Aerobic Intensity( ‫األنشطة الهوائية المرتفعة الشدة‬
.)Muscular Strength( ‫القوة العضلية‬
.)Flexibility (
‫المرونة‬
‫األنشطة البدنية التي يتم فيها حمل الجسم‬
.)Weight-bearing
ACSM, 2000
Caspersen,
et al., 1998
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physical activity(
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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
Sweden 260 males
(6 yrs)
Eriksson & Lindgarde,
Diabetologia, 19991
Da Qing, China
China
577 males &
Females (6 yrs)
Pan, et al,
Diabetes Care, 1997
The Nurse’s
Health Study
USA
70,000
Nurses (8 yrs)
Hu, et al.,
JAMA, 1999
Finnish
Finland
523 males &
Females (4 yrs)
Tuomilehto, et al., N
Engl J Med, 2001
3234 males &
Females (3 yrs)
Diabetes Prev. Program
Research Group,
Experimental
Study
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
Plasma Glucose (mmol/l)
20
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
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Response to 100 g of glucose in mild Type 2 Diabetics
12 months of Training
Plasma Insulin (pmol/l)
1600
1200
800
400
Before
After
0
0
30
60
90
120
150
180
Time (min)
Holloszy, et al. Acta Medica Scand 1986, 711: 55-65
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Exercise
Prescription
for Diabetic
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Exercise Prescription for Diabetic
1/4
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
2/4
Exercise must be regular. Benefits are
diminished after 1 -2 weeks of stopping .
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
3/4
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
4/4
It is recommended before any moderate to
high intensity exercise, especially if:
 Age is > 35 yrs.
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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:
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Takes insulin or diabetes pill.
Skips a meal.
Exercises for a long time.
Exercises strenuously.
If it occurs, what can be done?
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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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