Presentation on theme: "DIABETES MELLITUS AND EXERCISE"— Presentation transcript:
1DIABETES MELLITUS AND EXERCISE Josh Lewis MDFairfax Family PracticePrimary Care Sports Medicine FellowshipThanks to:CDR W. Bruce Adams, MC, USN
2OBJECTIVESTo review and compare exercise metabolism ineuglycemic and diabetic patientsTo provide guidance for counseling andmanagement of diabetics in pursuit of exercise
3INTRODUCTION Exercise is a key element in DM management delaying Diabetes (particularly Type 2) is a growing problem in the USExercise is a key element in DM management delayingdevelopment of Type 2 DMGoals of exercise:Improve overall health and fitness- cardiovascular endurance- strength- body fat compositionPsychological gains- less stigmatization- improved self confidence- socialization- healthier lifestyle attitude
4Half of these undiagnosed Demographics:Estimated ~ 6% of US population diabeticHalf of these undiagnosedType 1 Diabetics (5-10% of DM) WANT TO EXERCISE BUT SOMETIMESSHOULDN’TType 2 Diabetics (90-95% of DM) WON’T EXERCISE BUT SHOULD AT ALLTIMES
5DIABETES CLASSIFICATION: DIABETES MELLITUSDEFINITION:A group of metabolic diseases characterized by hyperglycemiaresulting from defects in insulin secretion, insulin action, or both.DIABETES CLASSIFICATION:New nomenclature for classes of diabetes mellitus established in1997 by the Expert Committee on the Diagnosis and Classificationof Diabetes Mellitus to help standardize terminology and addressinconsistencies between terminology and pathophysiology.
6TYPE 1 DIABETES MELLITUS [a.k.a. Type I DM, NIDDM, Juvenile-Onset DM]Deficiency of insulinProne to ketoacidosis-cell destruction:Immune mediatedIdiopathic (no evidence of autoimmune etiology)
7[a.k.a. Type II DM, IDDM, Adult-Onset DM] TYPE 2 DIABETES MELLITUS[a.k.a. Type II DM, IDDM, Adult-Onset DM]State of insulin resistance withrelative insulin deficiencyorPredominant deficiency ofinsulin with resistanceto insulin action
8OTHER SPECIFIC TYPES OF DIABETES: Genetic Defects of -Cell FunctionGenetic Defects in Insulin ActionDiseases of Exocrine PancreasEndocrinopathies (Cushing's syndrome,pheochromocytoma, other tumorsproducing excess of glucagon, growthhormone, somatostatin and aldosterone)Drug/Chemical InducedPost InfectionOther Uncommon Immune Mediated Forms(Insulin receptor antibodies, other autoimmunediseases)Associated Genetic Syndromes (Down's,Turner's, Kleinfelters syndrome, and others)
9GESTATIONAL DIABETES MELLITUS - Any degree of glucose intolerance first detected during pregnancy- Complicates ~ 4% of all pregnancies in US- Screening: 50 g oral glucose loadcheck 1 hr post load plasma glucoseIf > 140 mg/dl check 3 hr GTTDX: 2 or more elevated values on 3 hr GTT
11IMPAIRED FASTING GLUCOSE (IFG): IMPAIRED GLUCOSE TOLERANCE (IGT):A state between normal glucose homeostasis and diabetesHigh risk for progression to DMPathologic only in pregnancy?FASTING PLASM GLUCOSE > 110 but < 126 mg/dlIMPAIRED FASTING GLUCOSE (IFG):Older term used in conjunction with previous classificationscheme to describe the state between normal glucose homeostasisand diabetesFASTING PLASM GLUCOSE > 110 but < 140 mg/dl
12ENERGY FUELS FOR EXERCISE GLUCOSE (Intestinal Absorption, Blood Stream, Liver and Muscle)The basic carbohydrate for energy productionReadily transferred between bloodstream and liver or muscleGLYCOGEN (Muscle and Liver)Storage form of carbohydrate (glucose) in muscle and liverFuel source that is readily mobilized providing glucoseTRIGLYCERIDES (Adipose Tissue and Muscle)High yield-slow release form of energy storageProvides twice the energy per gram than carbohydrateLYPOLYSIS yields free fatty acids and glycerolPROTEIN (Liver)Minimal energy contribution (~10%) through gluconeogensis
14PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS HORMONAL CHANGES WITH EXERCISEIN NON-DIABETICSINSULIN levels declineGLUCAGON risesCATECHOLAMINES rise.Glycogen stores progressively become depleted.Later glucose availability is from gluconeogensis or ingestedglucose.
15PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS HORMONAL CHANGES WITH EXERCISE IN DIABETICSINSULINNormal physiologic decline in insulin with exercise absentAccelerated absorption from injection site levels above non-exercising baselineMuch individual variation re: injection site absorption patternsInsulin sensitivity in Type 2 DM enhanced with exercisejust 3-4 days/week
16PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS HORMONAL CHANGES WITH EXERCISE IN DIABETICSCATECHOLAMINESRelease may be abnormal dueto autonomic dysfunction.GLUCAGONDeficiency is common in diabetics.
17PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS GLUCOSE METABOLISM IN EXERCISEEnergy expenditure for exercise centers around mobilizationand metabolism of glucose for early energy expenditure subsequentlyaugmented by breakdown of triglycerides yielding (free fatty acidsand glycerol) for prolonged energy expenditure.Glucose homeostasis depends on the coordination between glucoseintake, storage and utilization directed by an intricate balance betweeninsulin and the counter-regulatory hormones activity.
18PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS EXERCISE AND GLUCOSE METABOLISMIN NON-DIABETICSSlight blood glucose initially then stabilizes- counter-regulatory hormones- glycogen stores- carbohydrate intake during exerciseSkeletal muscle glucose uptake - enhanced responsiveness to insulin- activation of direct myocyte uptake (independent of insulin)Baseline serum glucose in the long term- efficiency of glucose transport, storage and mobilization
19PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS EXERCISE AND GLUCOSE METABOLISMIN EXERCISE IN DIABETICSTrends not as predictable (interplay of multiple factors)Injected insulin cannot mimic the physiologic patterns glucose uptake and utilization serum glucose in both Type 1 and Type 2 response to insulindecreased glucose for given dose of insulin
20PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS EXERCISE AND GLUCOSE METABOLISMIN EXERCISE IN DIABETICSCaveats:Ketosis prone diabetics tend to have elevation of serumglucoseDiabetic children prone to greater variability in bloodglucose response
21EXERCISE GLUCOSE METABOLISM IN DIABETICS FACTORS AFFECTINGEXERCISE GLUCOSE METABOLISM IN DIABETICSPHYSIOLOGIC PHARMACOLOCICFACTORS FACTORSStatus of Metabolic Type of Insulin / OralControl Hypoglycemic AgentFitness Level Site of Insulin InjectionBlood Glucose at Time of Insulin InjectionOnset of ExerciseInsulin Resistance
22EXERCISE GLUCOSE METABOLISM IN DIABETICS FACTORS AFFECTINGEXERCISE GLUCOSE METABOLISM IN DIABETICSEXERCISE CALORICFACTORS INTAKETiming of Exercise Timing of Pre-Intensity of Exercise Exercise MealDuration of Exercise Caloric Content ofType of Exercise Pre-Exercise MealFrequency of Exercise (Quantity and Type)
23PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS LIPID METABOLISM AND EXERCISENON-DIABETIC DIABETIC HDL Cholesterol HDL Cholesterol LDL Cholesterol LDL Cholesterol (variable) Total Cholesterol Total Cholesterol VLDL VLDL- Exercise in diabetics has same beneficial effects on lipids asnon-diabetics, though greatest achievable gains are in Type 2 DM- These effects often attenuated in diabetes and degree ofimprovement somewhat correlates with adequacy of glycemic control.
24PHYSIOLOGIC EFFECTS OF EXERCISE IN NON-DIABETICS VS DIABETICS HYPERTENSION AND EXERCISENON-DIABETICS DIABETICS Systolic and Diastolic BP Systolic and Diastolic BP
25GUIDELINES FOR EXERCISE IN DIABETES GENERAL RECOMMENDATIONS- Most of the general principles for exercise in non-diabeticsare applicable to diabetics- Attention to carbohydrate intake and utilization must be morevigilant in the diabetic- Prescreening for comorbid conditions frequently associatedwith DM
26PRE-EXERCISE EVALUATION History and Physical Exam carefully assessing for:- Cardiovascular Disease- Peripheral Vascular Disease- Retinopathy- Nephropathy- Autonomic Neuropathy- Peripheral Neuropathy
27EXERCISE PLANNINGBalance Motivation vs. Capability vs. Type of Exercise NeededTarget: Aerobic exercise at 50-70% VO2 max minutes/day4-7 days/weekPursue exercise activities patient likely to find enjoyableSafetyGradual progression (higher risk of hypoglycemia with rapidprogression in untrained individuals)Proficiency in self blood glucose monitoring and insulin /carbohydrate adjustment
28EXERCISE ACTIVITIESMaintain a standardized exercise regimen avoiding major varianceSelf blood glucose monitoring before, during and after exerciseis paramount.Attention to caloric intake before during and after exercise,especially events >1hrAttention to hydration before during and after exercise,Avoid exercising at extremes of temperature when autonomicneuropathy presentAvoid exercising when sick.Warm Up (5-10 min low intensity aerobic) and Cool Down(5-10 min)Exercise at Moderate Intensity(50-70% MVO2 or PMHR, or RPE = 12-13)
29NUTRIENT INTAKEEat a meal 1-3 hours before exerciseCarbohydrate snack minutes before exercise protects againstpost-exercise hypoglycemiaCarbohydrate for Replacement of Glycogen Stores Meals: 60% Carbohydrate Exercise < 1 Hr/Day g/kg/day Exercise > 2 Hr/Day g/kg/day Coordinate Insulin dose/activity with food intakeIngest supplemental carbohydrate during exercise for exercise> 1 hr g/hr divided every minutes
30NUTRIENT INTAKEFluid IntakeNeed correlates to losses - depends on factors of heat, humidity,sweat rate and duration of exertionThirst is poor indicator of fluid need during exercise Weight loss most accurate: 1 lb. wt loss 15 oz (450 cc)water [add to fluid consumed] General guide: 8 oz (240 cc) every 20 minutesIngestion of Carbohydrate drink of 6-8% CHO during exercisetypically meets fluid and carbohydrate intake need
31SPECIAL CONSIDERATIONS INSULIN ABSORPTIONAbsorption rates from different injection sites not consistentlypredictable between different individualsAbsorption from ABDOMEN is FASTER AT REST than fromextremitiesAbsorption from ABDOMEN is MORE CONSISTANT thanfrom extremitiesAbsorption is accelerated when injected into area of exertionDelaying exercise 30 minutes after injection of Lispro allowsbetter glycemic control for exercise period
32ORAL HYPOGLCEMIC AGENTS Potential to cause hypoglycemia may be potentiated for severalagents, though risk typically less than for patients who requireinsulin.Sulfonylureas : most commonly associated with hypoglycemiametformin : avoid dehydration: potential for lactic acidosis
33HYPOGLYCEMIAMay arise from one or more of: Excess exogenous insulin Inadequate calorie intake Exercise / Caloric Expendituregreater than anticipated Typically occurs after exercise, Late Onset Hypoglycemiamore commonDue to dangers of hypoglycemic state SCUBA Diving, Rock Climbing,and Long Distance Swimming are contraindicated in diabetics
34Late Onset Hypoglycemia May occur 6 to 28 hours after strenuous exerciseMay be more of a problem for some diabetics thanhypoglycemia during exercise.Typically nocturnal; often severe with seizures or coma.Due to: Depletion of glycogen stores. Inadequate replenishment of glycogen stores postexercise. Increased sensitivity to insulin post exercise. Increased glucose uptake and glycogen synthesis indepleted muscle groups.Most commonly associated with prolonged strenuous exertionin individuals unaccustomed to such or after periods ofprolonged inactivity.Late afternoon/early evening exercise higher risk
35HYPERGLYCEMIA POST EXERCISE Insulin deficiency Decreased cellular uptake of glucose Increase in liver glucose productionCounter-regulatory hormone excess (stimulated by highintensity exercise) Excess hepatic glucose release
36Diabetics at significant risk for SILENT ISCHEMIA CARDIAC DISEASEDiabetics at significant risk forSILENT ISCHEMIACARDIAC AUTONOMIC NEUROPATHY GRADED EXERCISE STRESS TEST for any oneof the following:Age > 35 yearsType 2 DM > 10 years durationType 1 DM > 15 years durationAny additional CAD Risk FactorEvidence of Microvascular DiseasePeripheral Vascular DiseaseAutonomic Neuropathy(If Stress Test or Baseline EKG suspiciousperform RADIONUCLEOTIDE STRESS TESTING)
37CARDIAC DISEASEKnown CADEvaluate ischemic response to exercise/ischemic thresholdand propensity to dysrhythmia
38PERIPHERAL ARTERY DISEASE If symptoms of claudication or signs of arterial insufficiency Doppler pressure studies Closely supervisedexercise program
39PERIPHERAL NEUROPATHY Assess DTR’s, vibratory sense, position sense, and light touch(5.07 / 10g monofilament)Protective foot wear:socks that minimize friction(polyester or cotton –polyester blend)shoes with air or silica gel midsoleswell fitted to footFrequent inspection of feet for rubbing/wear areas,blisters vigilance against injury to feet is paramount.IF PROTECTIVE SENSATION LOST AVOID RUNNING OR PROLONGED EXERCISE WALKING
40AUTONOMIC NEUROPATHYProne to HYPERTENSION or HYPOTENSION after vigorousexercise, especially when first initiating exercise programDifficulty with THERMOREGULATION AVOID EXERCISE IN EXTREMES OF TEMPERATURECardiac Autonomic Neuropathy (CAN) suggested by restingtachycardia, orthostasis, with other organ system autonomicdysfunction. THALLIUM PERFUSION STUDY RECOMMENDED
41RETINOPATHYIf have PROLIFERATIVE DIABETIC RETINOPATHY (PDR)vigorous or strenuous activity may precipitate vitreous hemorrhageor retinal detachment. Avoid exercise involving straining or Valsalva-like maneuvers Avoid anaerobic exercise Avoid altitude sportsNEPHROPATHYRecommended to avoid high intensity or strenuous exercise(though not well studied).
42SPECIFIC GUIDANCE BY TYPE OF DIABETES TYPE 1 DIABETES1. Estimate energy requirement of planned exercise2. Pre-exercise planning:Timing Intensity & Duration of ExercisePre-breakfast exercise typically lower risk forhypoglycemiaDecrease insulin / increase carbohydrate for increasedintensity or durationCarbohydrate Ingestion Before During and After ExerciseType of carbohydrate important as is amount andfrequency of ingestionInsulin AdjustmentsType: short-acting allows easier adjustment
43SPECIFIC GUIDANCE BY TYPE OF DIABETES TYPE 1 DIABETES (cont’d)3. Monitor blood glucose before, during and after exercise.- Watch rate of change as well as absolute glucose value- More frequent monitoring with new programs or modificationsto training regimen.- More frequent monitoring with prolonged exercise orendurance events
45SPECIFIC GUIDANCE BY TYPE OF DIABETES TYPE 1 DIABETES (cont’d)4. Insulin management:Multi-dose regimen allows better flexibilityInsulin pump (Continuous Subcutaneous Insulin Infusionor CSII) may allow tighter titration- reduce pre-meal insulin bolus and basal infusion rateduring exercise (also post exercise for prolongedexertion)Short Acting (Humulog/Lispro) preferable- Wait 30 minutes after injection before exercise- Decrease short-acting insulin pre-exercise30% for exercise < 1 Hr40% for exercise Hr50% for exercise > 3 Hr
46TYPE 2 DIABETESHypoglycemia can occur with oral agentsMany patients now on combination regimens (combined oral hypo-glycemics / oral + insulin) requiring accounting for combinedeffects of each agentMay need to modify oral hypoglycemic regimen as responseto insulin is enhancedWeight loss is key to improving glycemic control ( insulinresistance) in many Type 2 diabeticsTarget of minutes moderate intensity exercise at least4 days per weekCouple exercise regimen with diet planning to optimize treatment
47CONCLUSION- Benefits from exercise realized by non-diabetics can be achieved bydiabetic patients as well (though metabolic gains typically aregreatest for Type 2 DM).- Guidelines for exercise in uncomplicated diabetes are the sameas those for non-diabetics with the caveat of heightened vigilance forpotential complications related to diabetes.- Self blood glucose monitoring and flexible insulin regimens are keyelements to successful pursuit of exercise in Type 1 DM
48CONCLUSION- Screening and adjustment for co-morbid condition in diabetes iscrucial to avoid exercise related complications- Adjustments for insulin must be individualized as there is muchvariation in insulin pharmacokinetics and glycemic responsebetween Type 1 DM patients