james a. stone - diabetes update€¦ · umpierre (2011) physical activity advice only or...
TRANSCRIPT
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!
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!
How Should We Write an Exercise Prescription!
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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.
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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!
How Should We Write an Exercise Prescription!CV and Health Benefits of Exercise!
How Should We Write an Exercise Prescription!
• 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!
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!
How Should We Write an Exercise Prescription!
Church, Blair et al. Arch Intern Med (2005)165(18):2114-20
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4
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isk
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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
How Should We Write an Exercise Prescription!
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
How Should We Write an Exercise Prescription!
Look AHEAD – clinical endpoints
NEJM (2013)369:145-54 Composite endpoint: CAD, nf AMI, nf stroke, Hospitalisation for Angina
How Should We Write an Exercise Prescription!
NEJM (2013)369:145-54
Look AHEAD – Fitness
How Should We Write an Exercise Prescription!
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)
How Should We Write an Exercise Prescription!
How Should We Write an Exercise Prescription!
• The Benefits of Exercise!• In Diabetes!
• The Principles of Exercise Prescription!• Be FITT SMART!
• In Diabetes – Special Considerations!• Summary!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
www.guidelines.diabetes.ca
• FITT!
How Should We Write an Exercise Prescription!
• SMART!
How Should We Write an Exercise Prescription!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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
How Should We Write an Exercise Prescription!
How Should We Write an Exercise Prescription!
How Should We Write an Exercise Prescription!
• The Benefits of Exercise!• In Diabetes!• The Principles of Exercise Prescription!• In Diabetes – Special Considerations!
• Summary!
How Should We Write an Exercise Prescription!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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]
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
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
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
CDA Clinical Practice Guidelines
http://guidelines.diabetes.ca – for professionals 1-800-BANTING (226-8464) http://diabetes.ca – for patients
• Patient Prescription Problems!
How Should We Write an Exercise Prescription!