1. Exercise therapy in type 2 diabetes: state of the art
Dominique Hansen, PhD, FESC

2. State-of-the-art exercise in T2DM
Effectiveness of exercise intervention
Prevention
Treatment
Novel/new exercise modalities
Experimental manupulations
Future of exercise therapy
Where do we go from here?

4. Prevention of T2DM

5. Prevention of T2DM

6. Treatment of T2DM
Qiu S, et al. PLoS One Oct 17;9(10):e109767

7. Treatment of T2DM
Umpierre D, et al. JAMA 2011; 305:

8. Treatment of T2DM

9. Treatment of T2DM
Umpierre D, et al. Diabetologia 2013; 56:

10. Optimizing exercises

11. Optimizing exercises

13. New/other exercise types

14. New/other exercise types

15. New/other exercise types

16. New/other exercise types

17. New/other exercise types
Changes in peripheral insulin sensitivity after three months of endurance type exercise training with exercise sessions performed in either a fasted (solid lines) or postprandial state (dotted lines).

18. New/other exercise types
Fasted
Postprandial
Time effect
Group *time
effect
Pretest
Posttest
P value
Fasting blood glucose (mmol/l)
11.4 ± 4.4
9.8 ± 5.0
9.0 ± 2.9
7.8 ± 2.0
<0.05 NS
HbA1c (%)
7.9 ± 1.8
7.7 ± 1.7
6.9 ± 0.9
6.7 ± 0.9
HbA1c (mmol/l)
63 ± 7
61 ± 7
52 ± 4
50 ± 4
M (mg/kg/min)
11.6 ± 12.9
20.6 ± 17.9
14.5 ± 15.7
25.1 ± 18.6
<0.01

19. New/other exercise types

20. New/other exercise types

21. New/other exercise types

22. New/other exercise types

23. New/other exercise types

24. New/other exercise types

26. Difficulties ahead
Type 2 diabetes

27. Difficulties ahead AMI with PCI or CABG Hypercholesterolemia
Heart failure
Hypertension
Sarcopenia
Cardiomyopathy
Type 2 diabetes
Obesity
Pacemaker/ICD
Claudicating intermittens

28. And what to do with prescription of certain medications?
Difficulties ahead
And what to do with prescription of certain medications?
Beta-blockers
Statins
Sulfonylurea/meglitinide
Exogenous insulin administration …
And what to do with certain adverse events during exercise testing?
Myocardial ischemia
Exercise-induced cardiac arrhythmias

29. And what to do with prescription of certain medications?
Difficulties ahead
And what to do with prescription of certain medications?
Beta-blockers
Statins
Sulfonylurea/meglitinide
Exogenous insulin administration …
And what about safety precautions during exercise for all these indications?
Nobody really knows….

30. Comparing different clinicians

31. Comparing different clinicians
Case 1
Case 2
Case 3
Case 4
Case 5
Age: 65 years
Body height: cm
Body weight: 65 kg
Sex: male
VO2max: ml/min (116% of predicted normal value)
Resting HR: 55 bts/min
Peak exercise HR: 123 bts/min
Total cholesterol: 180 mg/dl
Fasting glycaemia: 92 mg/dl
Blood pressure: 145/82 mmHg
Medication intake: beta-blocker, nitrate, statin, antiplatelet.
Referred to rehabilitation for: acute myocardial infarction with PCI.
Co-morbidities: None.
Age: 55 years
Body height: cm
Body weight: 85 kg
Sex: female
VO2max: ml/min (108% of predicted normal value)
Resting HR: 102 bts/min
Peak exercise HR: 151 bts/min
Total cholesterol: 267 mg/dl
Fasting glycaemia: 108 mg/dl
Blood pressure: 115/72 mmHg
Medication intake: statin, ACE-inhibitor, orlistat, antiplatelet, metformin, sulfonylurea.
Referred to rehabilitation for: obesity.
Co-morbidities: type 2 diabetes.
Additional information: gonarthrosis present.
Age: 70 years
Body height: cm
Body weight: 80 kg
VO2max: ml/min (73% of predicted normal value)
Resting HR: 52 bts/min
Peak exercise HR: 112 bts/min
Total cholesterol: 189 mg/dl
Fasting glycaemia: 102 mg/dl
Blood pressure: 125/80 mmHg
Medication intake: statin, antiplatelet, beta-blocker, digitalis, mucolytics, bronchodilators.
Referred to rehabilitation for: AMI with CABG.
Co-morbidities: Heart failure with preserved ejection fraction, mild COPD.
Body height: cm
Body weight: 90 kg
VO2max: ml/min (90% of predicted normal value)
Resting HR: 52 bts/min
Peak exercise HR: 100 bts/min
Total cholesterol: 234 mg/dl
Fasting glycaemia: 115 mg/dl
Blood pressure: 135/75 mmHg
Medication intake: beta-blocker, statin, exogenous insulin, nitrate, erythropoietin.
Referred to rehabilitation for: stable myocardial ischemia (threshold at 87 bts/min)
Co-morbidities: renal failure, type 1 diabetes.
Additional information: chronic aspecific low back pain present.
Age: 79 years
Body height: cm
Body weight: 59 kg
VO2max: ml/min (88% of predicted normal value)
Resting HR: 56 bts/min
Peak exercise HR: 111 bts/min
Total cholesterol: 178 mg/dl
Fasting glycaemia: 125 mg/dl
Blood pressure: 135/87 mmHg
Medication intake: beta-blocker, bronchodilator, antiplatelet.
Referred to rehabilitation for: peripheral vascular disease.
Co-morbidities: cachexia and frailty, COPD.

32. Comparing different clinicians

33. Comparing different clinicians

34. Comparing different clinicians

35. Need for standardization

36. EXPERT tool

37. EXPERT tool

38. EXPERT tool

39. EXPERT tool

40. EXPERT tool

41. EXPERT Tool
Digital, interactive decision support tool for exercise prescription
Endorsed by the European Association of Preventive Cardiology

42. Time for telemedicine?

43. Drug-exercise interaction?+ =
Enhanced effects of exercise? + =
Enhanced effects of drugs?

44. One last thing to (re)consider…
But how, by what mechanism?
By HbA1c reduction only?

45. Or maybe two things to (re)consider?
This is often what we aim for….
But this is what we should aim for….