exercise training in diabetes prof. dr. dominique hansen

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

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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: Dominique.hansen@uhasselt.be