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Diabetes Mellitus

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Transcript of Diabetes Mellitus

- AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire
PAR-Q

- ACSM risk classification model: Type 1 Diabetes (known metabolic disease) = High Risk

- Be aware of pre-diabetes as it is one of the CVD risk factors

- Medical exam for moderate and vigorous exercise

- Exercise test before exercise for moderate and vigorous exercise

- MD supervision of exercise test for submaximal and maximal

Glycemic Control
- Patient self-monitoring of blood glucose

Insulin Pump
- May deliver rapid or short acting insulin 24 hours a day through a catheter placed under the skin (Provides: Basal Rates, Bolus Doses, Correctional/Supplemental Doses)
- Disadvantages:
- Can cause weight gain
- Can cause diabetic ketoacidosis if the catheter comes out
- Can be expensive
- Bothersome – the pump remains attached for long periods
- Can require hospital stay to be trained

Other Injectable Medications
- Exenatide – enhances insulin secretion while decreasing glucose output from the liver
- Disadvantage: risk of
hypoglycemia
- Liraglutide – may cause nausea
- Pramlintide – slows food from moving quickly through the stomach, keeping after-meal glucose levels from spiking
- Disadvantage: can
suppress appetite
and cause
weight loss
, may cause
nausea
Medications and their Effects
Recommendations for Exercise Programs
Recommendations for Pre-Exercise Screening
Aerobic Training
Resistance Training
Danielle Carnegie, Natalie Doucette, Brian Findlay, Leirick Chung
Tuesday, October 7, 2014
Vol XCIII, No. 311
Type I Diabetes
Precautions and Recommendations
Diabetes Mellitus
Juvenile Diabetes / Insulin-Dependent Diabetes / Type I
Purpose
: Determine glycemic control responses with resistance training in type 1 DM patients

Research Design
(level of evidence): Oxford Scale: level 3b

Methods
: 6 men and 6 women with T1DM performed resistance training which included chest-fly exercises, leg curls, latissimus dorsi pull downs, leg extensions and biceps curls

Blood glucose was measured at rest, after warm-up, immediately after last set of each exercise and 10, 20, 30 min after each exercise

Results
:

• Reduction in blood glucose after 40%, 60% and 80% of 1RM
• Moderate and high intensities had a greater magnitude (large) in effect size compared to low intensity (small to moderate)
• Reduction in blood glucose levels did not differ significantly between 60% and 80% of 1RM
• Recommendations: sedentary individuals exercise at 40% 1RM and patients with no contraindications can exercise at 60 to 80% 1RM for glycemic control
Publications
What is Diabetes?
- A condition that in where a person’s
pancreas
does not produce enough insulin

- Insulin is responsible for processing
glucose

- It is a
genetic disorder
and is usually diagnosed in childhood or adolescence and requires lifelong insulin treatment

- Diagnosed based on plasma glucose criteria:
- either the fasting plasma glucose (FPG)
- Or the 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT).

(Torpy 2009)
Pathophysiology
- It is considered an
auto-immune
condition

-
Beta cells
in the islets of Langerhans in the Pancreas are responsible for producing the body’s insulin

- Insulin facilitates glucose absorption into tissues

- Therefore less insulin results in
elevated blood glucose levels
Key Symptoms
- Excessive Thirst

- Fatigue

- Frequent Illness or Infections

- Poor Circulation
- Tingling or numbness in the feet or hands

- Wounds that do not heal

- Blurred Vision

- Unintentional Weight Loss (Torpy 2009)
Negative Effects
- Hyperglycemia

- Polydipsia

- Polyuria

- Polyphagia

- Diabetic Retinopathy -> blindness

- Diabetic Neuropathy - loss of sensation

- Ulcers -> amputations

- Unexplained weight loss
Severe Complications
- *Heart Disease (evidence of both systolic and diastolic left ventricular dysfunction in diabetic individuals in whom there was no clinical evidence of coronary artery disease)

- Vascular Disease
- Poor Circulation
- Blindness
- Kidney Failure
- Poor Healing
- Stroke
- Neurological Disease
- Ketoacidosis
*Complications from diabetes can be prevented with careful blood sugar management and control of high blood pressure and high cholesterol levels when present.
Impact of Diabetes
Aerobic Fitness
- Reduced VO2peak in adolescents with type 1 diabetes (Nadeau et al, 2010)

- Lower VO2max in individuals who do not control their type 1 diabetes well (Tagougui et al, 2014)

- Decreased aerobic capacity from:
-decreased maximal SV
-decreased lung volume
-decreased maximal O2 uptake (Niranjan et al, 1997)

- Decreased autonomic and cardiovascular function (Limberg et al, 2014)

- Higher risk of cardiovascular issues:
-CAD
- angina
- heart attack
- stroke
- atherosclerosis
- high blood pressure (mayoclinic)
Physical Function
-
Contractile Protein
– Insulin’s Anti-Catabolic Characteristics
(GreenHaff et al 2008)

-
Heart and Blood Vessels
– increases your risk factors for developing various cardiovascular problems

-
Neuropathy
– loss of sense of feeling and impaired vision, damage to nerves that supply the gastrointestinal tract can cause problems with nausea, vomiting, diarrhea or constipation, and in men erectile dysfunction

-
Nephropathy
– Kidney damage leading to kidney disease (dialysis)

-
Eye Damage
– Diabetic Retinopathy (damage to vessels supplying the retina), blindness, cataracts, glaucoma

-
Foot Damage
– due to nerve damage and poor blood flow

-
Skin and mouth conditions

-
Cognitive Impacts
– decreased mental speed and mental flexibility (hampers everyday activities since they can be expected to present problems in more demanding situations
- Difficulty applying acquired knowledge in a new situation
(Brands et. Al 2005) (The Mayo Clinic)
Psychological Impact
-
Fear of hypoglycemia
is the largest barrier to physical activity (Brazeau, 2008)

- Reduced mental speed, flexibility, general intelligence (fluid & crystallized), information processing speed, psychomotor efficiency, visual perception & visual and sustained attention (Brands, 2005)

- Small to moderate
decrease in cognitive performance
in T1DM vs. non-diabetics (Tonoli, 2014)

- Children performed worse in executive function, full IQ & motor speed (Tonoli, 2014)

- Adults performed worse in full, verbal and performance IQ, part of executive function, memory, partial memory & motor speed (Tonoli, 2014)

-
Depression
(Tonoli, 2014)

Mortality Risk
- Despite a significant improvement since the advent of insulin therapy, those with T1DM remain at risk of premature mortality compared to those without the disease. (Distiller, 2014)

- Increased mortality is most commonly due to cardiovascular disease (CVD) which is increased in those with Type1DM (Chemin et al., 2012)

- More specifically, risk of CVD depends upon:
- Glycemic control
- Blood pressure
- Lipids control
- Healthy body weight maintenance (Distiller, 2014)

- Decreased autonomic and cardiovascular function- could lead to increased risk of mortality (Limberg et al, 2014)

Quality of Life
- The sense of total well-being that encompasses both physical and psychosocial aspects of an individual’s life (O’Sullivan, Schmitz, & Fulk, 2014).

- Overall decreased quality of life, especially in physical functioning and well-being domains of QOL (Rubin, & Peyrot, 1999)

- Patients with T1DM must constantly self-manage their disease to maintain proper glycemic control and reduce risk of complications→ added stress

- Patients with better long-term glycemic control tend to have better reported QOL (Rubin, & Peyrot, 1999)

- The incidence of depression is 3X that of the general population (Chemin et al., 2012)

- Depression has a severe impact on quality of life, especially in this population (Goldney, Fisher, Phillips, & Wilson, 2004)

- Chronic neuropathic pain is associated with impaired QOL (Benbow, Wallymahmed, & Macfarlane, 1998)

- Diabetic Quality of Life questionnaire (DQOL)
Precautions
- Higher risk of
sudden cardiac death
(Turker et al, 2013)

- Individuals with type 1 diabetes are at high risk for
hypoglycemia
during exercise

- Increased
insulin sensitivity

- Muscles contract during exercise and cells take in glucose

- Hypoglycemia can happen during exercise, directly after exercise, and hours later (American Diabetes Association:Position Statement)

-
Hyperglycemia
can occur in very intense exercise (Canadian Diabetes Association:Clinical Practice Guidelines)

- Wear
proper footwear
(peripheral neuropathy) (American Diabetes Association:Position Statement)

Recommended Accomodations
-
Pre-test instructions
may have to change in this population:
- “Refrain from ingesting food, alcohol or caffeine within 3 hours of test”
- Carbohydrates necessary before and after exercise to avoid hypoglycemia (American Diabetes Association:Position Statement)

- Allow the individual to
drink water
before exercise test is important to avoid dehydration
- dehydration can alter blood glucose levels and affect heart function (American Diabetes Association:Position Statement)

-
Insulin adjustments
may be required (American Diabetes Association:Position Statement)

-
Monitoring of blood glucose levels
before and after exercise test (American Diabetes Association:Position Statement)

- Constantly
monitor CV symptoms

*Diabetes cannot be cured but can be successfully treated
Oral Medications
- Sulfonylureas – stimulates the beta cells of the pancreas to release more insulin
- Biguanides – decreases the amount of glucose produced by the liver
- Disadvantage: Diarrhea


Side Effects of other medications:
- Serious
liver problems
- Risk of
heart failure
- Increased glucose levels in the urine (urinary tract and yeast infections)
-
Flatulence, Constipation, Diarrhea

Alternative Approaches
- Islet transplantation (Islets are clusters of cells in the pancreas that make insulin)
-
Require immunosuppressive drugs
(they are already at an increased risk of infection
- Kidney Transplant –
Wait times
(not enough organ donors), still a risk fo the new kidney developing a diabetic neuropathy
- Not as safe for people who has heart or blood vessel disease – and we know that people with Diabetes are at higher risk for these things

(American Diabetes Association – Standards for Medical Care in Diabetes in 2014)
Good News!
Studies consistently demonstrate that
physical activity
is associated with reduced insulin requirements (Chemin et al, 2012)
(ACSM, 2013)
(ACSM, 2013)
Silveira et al. (2014). Acute effects of different intensities of resistance training on glycemic fluctuations in patients with type 1 diabetes mellitus.
D’hooge et al. (2011). Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial.
Benefits of Exercise
*Due to the physiological nature of T1DM, the disease cannot be prevented or reversed; however, evidence shows that physical activity is an important tool in improving and managing negative consequences of the disease.
Aerobic Fitness
-
Increased insulin sensitivity
during and following moderate aerobic exercise (Canadian Diabetes Association:Clinical Practice Guidelines)


- Multiple studies show
decreased insulin requirements
in association with physical activity (Chimen et al, 2012)

Physical Function
- Long term aerobic exercise can
prevent diabetic peripheral neuropathy
or alter it’s course in individuals with type 1 and type 2 diabetes (Balducci et al, 2006)


- Exercise related to
improvement of lipid levels
of those with type 1 diabetes (Chimen et al, 2012)


-
Improved glycemic control
(findings in the literature vary) (Salem et al, 2010)

Psychological Impact
- Exercise and
psychological well-being
positively associated in individuals with type 1 diabetes (Edmunds et al, 2007)


- Specific example from Stewart et al, 1994
Individuals who rated themselves as highly active also reported
higher perceived psychological health
compared to less active individuals

Mortality Risk
- Association between
CVD
and low physical activity in people with type 1 diabetes (Chemin et al. 2012)

- Physical activity aids in reduction of apolipoprotein B, a pro-atherogenic, therefore
reducing risk of CVD
(Chemin et al, 2012)

- Men with type 1 diabetes who played team sports as youth had
3X lower mortality rates
than men with type 1 diabetes who did not participate (Chemin et al., 2012)

- Overall, mortality and CVD among those with type 1 diabetes are shown to be reduced with physical activity (chemin et al., 2012)

Quality of Life
- Physical activity is associated with
significantly greater well-being and life satisfaction
in people with diabetes (Chemin et al., 2012)


- D’hooge et al. (2011) found that adolescents who did both aerobic and strength training reported better quality of life (in particular, the domains of
general health, vitality, and emotional functioning
).


- Intuitively, the benefits of physical activity on the previously mentioned aspects of well-being (psychological and physical function) contribute to improved QOL

Special Considerations
Altered perception of ischaemic cardiac pain
- This may deprive diabetic patients of the signal to stop exercising allowing ischaemia to intensify to the point that arrhythmias are triggered.
(Timmis 2001)

Autonomic neuropathy
- This may also interfere with pain perception during plaque events, delaying presentation to hospital
Hypoglycemia
- Occurs when blood glucose is lower than normal (below 70mg/dL)
- Exercise increases sensitivity to insulin therefore individuals are at risk of a low after exercise
- Be aware of the
signs
:
- Hunger
- Nervousness
- Shakiness
- Perspiration
- Dizziness or light-headedness
- Sleepiness
- Confusion
- If left untreated can lead to loss of consciousness

*If you experience hypoglycemia during or after exercise, treat it immediately. Use the same process as you would any other time of the day:

1
) Have at least 15-20 grams of fast-acting carbohydrate (sports drinks, regular soda, or glucose tabs are all good ideas).

2
) Wait 15-20 minutes and check your blood glucose again.

3
) If it is still low and your symptoms of hypoglycemia don't go away, repeat the treatment.

4
) After you feel better, be sure to eat regular meals and snacks as planned to keep your blood glucose level up.
Treatment and Care for African Americans

- Compared to the general population, African Americans are disproportionately affected by diabetes:
- African Americans are 1.7 times more likely to have diabetes as non Hispanic whites.

- Certain populations are at a greater risk for life-threatening complications

- African-Americans are significantly more likely to suffer from blindness, kidney disease and amputations
(American Diabetes Association)

Special Considerations:
-
Timing
of exercise in relation to insulin

-
Insulin pump
can become disconnected during exercise

-
Hyperglycemia
with or without ketosis

-
Dehydration
resulting from polyuria

- Compromised
thermoregulatory response

-
HR and BP responses
may be blunted (due to autonomic neuropathy)

- Proper
foot care
(ACSM Manual)
Key Points
:

Be on the lookout

Prepare

Check Often

(Diabetes.Org)
Summary
References
American College of Sports Medicine. (2013). ACSM’s guidelines for exercise testing and prescription (9th ed.).Lippincott Williams & Wilkins

American Diabetes Association. (2004). Physical activity/exercise and diabetes. Diabetes Care, 27, S58-S62.

American Diabetes Association. (2014). Standards of Medical Care in Diabetes. Diabetes Care vol. 37 no. Supplement 1 S14-S80

Benbow, S. J., Wallymahmed, M. E., & Macfarlane, I. A. (1998). Diabetic peripheral neuropathy and quality of life. QJM: An International Journal of Medicine, 91, 733-737.

Brands, A.M., Biessels G.J., de Haan E.H., Kappelle, L.J., Kessels R.P. (2005). The effect of type 1 diabetes on cognitive performance: a meta-analysis. Diabetes Care, 28 (3): 726-735.

Brazeau, A.S., Rabasa-Lhoret, R., Strychar, I., Mircescu, H. (2008) Barriers to physical activity among patients with type 1 diabetes. Diabetes Care, 11: 2108-2109.

Canadian Diabetes Association. (2013). Physical activity and diabetes. Canadian Journal of Diabetes, S40-S44.

Chimen, M., Kennedy, A., Nirantharakumar, K., Pang, T. T., Andrews, R., & Narendran. P. (2012). What are the health benefits of physical activity in type 1 diabetes mellitus? A literature review. Diabetologia, 55, 542-551.

D’hooge, R., Hellinckx, T., Van Laethem, C., Stegen, S., De Schepper, J., Van Aken, S., Dewolf, D., & Calders, P. (2011). Influence of combined aerobic and resistance training on metabolic control, cardiovascular fitness and quality of life in adolescents with type 1 diabetes: a randomized controlled trial. Clinical Rehabilitation, 25, 349-359.
Distiller, L. A. (2014). Why do some people with type 1 diabetes live so long? World Journal of Diabetes, 5(3), 282-287.

Edmunds, S., Roche, D., Stratton, G., Wallymahmed, K., & Glenn, S. M. (2007). Physical activity and psychological well-being in children with type 1 diabetes. Psychology, Health & Medicine, 12(3), 353-363.

Goldney, R. D., Phillips, P. J, Fisher, L. J., & Wilson, D. H. (2004). Diabetes, depression and quality of life: A population study. Diabetes Care, 27(5), 1066-1070.

Greenhaff, P., Karagounis, N., Peirce, E., Simpson, M., Layfield, R., Wacherhag, H., Smith, K., Atherton, P., Selby, A., Rennie, M., (2008) Disassociation between the effects of amino acids and insulin on signaling, uqiquitin ligases, and protein turnover in human muscle. American Journal of Physiological and Endocrinological Metabolism. 295: E595-E604

Limberg, J. K., Farni, K. E., Taylor, J. L., Dube, S., Basu, A., Basu, R., Wehrwein, E. A., & Joyner, M. J. (2014). Autonomic control during acute hypoglycemia in type 1 diabetes mellitus. Clin Auton Res.

Nadeau, K.J., Regensteiner, J.G., Bauer, T.A., et al (2010). Insulin resistance in adolescents with type 1 diabetes and its relationship to cardiovascular function. J Clin Endocrinol Metab 95(2), 513–521.

Niranjan, V., McBrayer, D. G., Ramirez, L. C., Raskin, P., & Hsia, C. C., (1997). Glyceminc control and cardiopulmonary function in patients with insulin-dependent diabetes mellitus. Am J Med, 103, 504-513.

O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. D. (2014). Physical rehabilitation (6th ed.). Philadelphia, PA: F. A. Davis Company

Rubin, R. R., & Peyrot, M. (1999). Quality of life and diabetes. Diabetes metabolism research and reviews, 15, 205-218.

Silveira, A. P. S., Bentes, C. M., Costa, P. B., Simao, R., Silva, F. C., Silva, R. P., & Novaes, J. S. (2014). Acute effects of different intensities of resistance training on glycemic fluctuations in patients with type 1 diabetes mellitus. Research in Sports Medicine, 22, 75-87.

Stewart, A. L., Hays, R. D., Wells, K. B., Rogers, W. H., Spritzer, K. L., & Greenfield, S. (1994). Long-term functioning and well-being outcomes associated with physical activity and exercise in patients with chronic conditions in the medical outcomes study. Journal of Clinical Epidemiology, 7, 719-730.

Tagougui, S., Leclair, E., Fontaine, P., Matran, R., Marais, G., Aucouturier, J., Descatoire, A., Vambergue, A., Oussaidene, K., Baquet, G., & Heyman, E. (2014). Muscle oxygen supply impairment during exercise in poorly controlled type 1 diabetes. American College of Sports Medicine.

Tonoli, C., Heyman, E., Roelands, B., Pattyn, N., Buyse, L., Piacentini, M.F., Berthoin, S., Meeusen, R. (2014). Type 1 diabetes-associated cognitive decline: A meta-analysis and update of the current literature. Journal of diabetes, 1- 15.

Torpy JM, Lynm C, Glass RM. Diabetes.JAMA. 2009;301(15):1620.

Timmis, A. D. (2001). Diabetes. British Medical Bulletin, 59(1), 159-172.

Turker, Y., Aslantas, Y., Aydin, Y., Demirin, H., Kutlucan, A., Tibilli, H., Turker, Y., & Ozhan, H. (2013). Heart rate variability and heart rate recovery in patients with type 1 diabetes mellitus. Acta Cardiol, 68(2), 145-150.


(http://www.diabetes.org/food-and-fitness/fitness/get-started-safely/blood-glucose-control-and-exercise.html)

http://www.mayoclinic.org/diseases-conditions/type-1-diabetes/basics/complications/con-20019573
Purpose
: Determine the effects of combined training (aerobic and resistance) on metabolic control, physical fitness and QOL in adolescents with type 1 diabetes.

Research Design
(level of evidence): PEDro scale 10: RCT, double-blind, sealed random allocation

Methods
: 16 adolescents (10-18 yo) were randomized into training group (n=8) (aerobic and resistance) & control group (n=8) (normal daily activities). Participants in training group exercised 2x per week for 70 min per session. Outcome measures were recorded pre- and post-training for training group and pre- and post-normal daily activities for non-training group.

The program consists of aerobic component (cycling, running and stepping) where week 1-6 = 60% of peak HR, week 7-12 = 70% of peak HR, week 13-20 = 75% of peak HR.

The resistance component included stack weight and fitness equipment for biceps, triceps, leg press, adductors. Week 1-6 = 2 sets of 15 reps at 20RM, week 7-12 = 2 sets of 12 reps at 17RM, week 13-20 = 3 sets of 10 reps at 12RM. Abdominal strengthening was also included: 2 sets of 20 sit-ups with knees up, knee down to left and knees down to right.

Results
:
• Overall, intervention resulted in improved physical fitness, positive impact (slight) on well-being and reduced daily insulin dose needed
• No significant difference in peak VO2, peak power and peak HR, but ratio of peak O2 consumption to peak power decreased significantly in training group while it did not change in control group
• Significant increase in muscle fatigue score (s), number of sit-to-stand, 6MWT distance (m), upper and lower limb strength while no changes occurred in the control group
Reduced daily insulin dose needed
No significant effect in QOL, but slight improvements in domains such as general health, emotional functioning and vitality.


1)
Pre-exercise screening for T1DM pts (high risk population) require
PAR-Q/AHA, medical exam and exercise test
(with MD supervision for both submaximal & maximal)

2)

Aerobic and resistance training
have positive benefits: ↑glycemic control, ↓insulin dose required, ↑physical fitness and ↑QOL

3)
With
careful monitoring of blood glucose levels
, exercise and physical activity can be a safe and effective way for individuals to better manage their type 1 diabetes
Full transcript