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Physical Activity, Prevention & Wellness: Obesity and Diabe

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Rebecca Irby

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Transcript of Physical Activity, Prevention & Wellness: Obesity and Diabe

Physical Activity, Wellness & Prevention:
Obesity & Diabetes

Rebecca B. Irby, PT, DPT, OCS

Physical Activity, Wellness & Prevention: Obesity & Diabetes

Objectives:
To be able to assess and define the terms overweight, obesity and diabetes.
To understand the basic cellular mechanism of diabetes development.
To understand the impact of obesity & diabetes on health risks.
To understand the relationship between excess weight and
physical activity & fitness as pertains to diabetic prevention & management.
To identify the role of physical activity in prevention and treatment of obesity.
Defining Overweight vs. Obesity
BMI: index of weight divided by height (kg/m2)
Underweight: <18.5
Normal weight: 18.5 to 24.9
Overweight: 25 to 29.9
Obesity: >30

Waist Circumference: measured at iliac crest, increased health risk with greater waist circumference
Men: over 102 cm (~40")
Women: over 88 cm (~35")
As good of a marker of total fat as BMI measurements

http://www.sihatselalu.com.my/2011/06/dangers-of-hidden-visceral-fat.html
Which measure is the best?
All fat is not created equal (neither are the measurement tools!)
Total fat measured in BMI may not account for gender, race, age, fitness level or genetics.
Location of adipose tissue in abdominal area may be a strong predictor of health risks, especially coronary heart dz.

Waist to Hip ratio:
waist circumference divided by hip circumference measured at largest point.

Skin fold measurements:
site specific, percentage of body fat, may be more direct & accurate in predicting total fat & health risks.
Adipokines
: proinflammatory
Leptin
- hormone that works in hypothalamus to regulates hunger, lipid metabolism, insulin secretion, immune function.
Resistin
- insulin resistance, inflammation, vascular function
The Positive Feedback Cycle of Obesity
Adipose tissue
Abdominal Fat
: fat distribution important determinant of cardiovascular & diabetes risks.
Subcutaneous fat
- between the dermis
Visceral (intra-abdominal) fat
- contained within the visceral peritoneum
Adipocytes are metabolically more active --> may cause insulin retention, sodium retention, inflammation, decreased immune system, hypertrophy of smooth ms.
http://www.nathanyoungsblog.com/visceral-fat-the-bad-belly-fat/
Effects in obesity

Leptin
- hypothesized leptin resistance, increased appetite, decrease fat used for energy, decrease insulin secretion, decrease immune function
Resistin
- increased insulin resistance & inflammation, vascular dysfunction
Health Implications of Obesity
Diabetes (58%)
Ischemic Heart Dz (21%)
Cancer (up to 42%?)
HTN
Dyslipedemia
CAD
Stroke
OA
Gallbladder Dz
Sleep apnea/breathing problems
Mental illness (depression, anxiety)
Higher Morbidity & Mortality Rates

Higher Health Care Costs
CDC estimated cost of obesity in 2008 -
$147 Billion US dollars
Current US health care costs related to obesity thought to be $200 Billion (20% of medical costs).
Worldwide cost - ??Estimated to be over $2 Trillion (more than combined cost of armed war, terrorism & war) reported in 2014 by Time magazine
http://www.cdc.gov/obesity/adult/causes/index.html
http://www.obesitycampaign.org/obesity_facts.asp
http://time.com/3597407/obesity-global-cost-report/
Cancer Studies
Varied and inconclusive - no RCT studies to show a correlation
However...American Cancer Society reports -
Suspect a link between adipokines & cancer in some cases.
Strongest links with colorectal, postmenopausal breast, endometrial, esophogeal, pancreas & kidney cancers.
Higher mortality rate in cancer cases combined with obesity.
Obesity is a modifiable risk factor.
World Cancer Research Fund "estimates 20% of all cancer dx in the US related to body fatness, physical inactivity, excess alcohol consumption and/or poor nutrition therefore, could have been prevented".
Obesity Prevalence & Cultural Trends
Worldwide
937 million overweight adults
396 million obese adults
High income countries - 50% of adults overweight & obese, 45% of school aged children overweight (15% obese)
USA (JAMA)
Obesity incidence 36% women, 34% men
Overweight/obese incidence 64% women, 72% men
Rachel Fredrickson - 2014 season 15 winner
Lost 155 lbs (from 260 to 105 lbs) in 8 month period.
7.3 million viewers watched finale.
Heart Attack Grill in Las Vegas: Triple Bypass Burger
"Taste worth dying for"
Exercise Training In Obesity
Leisure time physical activity
- the "workout" alone may not be adequate to off-set caloric intake
Is one hour per day enough to off-set the sedentary lifestyle?
Non-leisure time physical activity
- increased mvmt throughout the day
Fewer blue collar jobs than in 1970
Decreased use of walking and biking
Increased computer time & use of social media
Technological advances in housework
Exercise training benefits
Promotes loss of abdominal fat (even without caloric restriction)
Elevated energy expenditure following exercises - depends on type & intensity
Changes in glucose metabolism
http://en.ria.ru/world/20121127/177775421.html
Developing an Exercise Prescription:
Increased risk of orthopedic injuries, cardiovascular dz & heat intolerance
Consider motivation - psychological components?
Address progression & consistency
American College of Sports Med recommendations for weight loss:
200-300 min/week (30-60 min/day), daily or at least 5 days per week at 60-75% VO2 peak.
Dietary changes for Weight Loss
Low-calorie balanced diets

800-1200 calories per day for women or 1200-1400 calories per day for men
High fiber, low glycemic index
Low-fat diets
Fat calories 10-25% or less of total calories
Significantly lower total cholesterol, improve insulin sensitivity & reduce inflammation
Low-carbohydrate diets
Not recommended as healthy dietary lifestyle
Instead, choose carbs high in fiber & low in refined sugar

An effective weight loss program requires negative caloric balance.
Diabetes Mellitus: "flowing out of honey"
Most Common endocrine disorder:
unable to control blood glucose homeostasis via insufficient insulin production or inadequate organ response.
DX:
fasting plasma glucose >126mg/dl or 2-hour plasma glucose during oral glucose tolerance test >200mg/dl.
SX:
polyuria, polydipsia, polyphagia (the 3 P's), unexplained weight loss, fatigue, visual disturbances.
Type 1: "Juvenile"
Autoimmune d/o
5-10% diabetics
Pancreatic Beta-cells (trigger release of insulin) viewed as foreign body & are destroyed
hypoinsulinemia
TX: insulin injections
Type II: Adult onset
Metabolic d/o (linked to obesity)
90-95% of diabetics
Pancreatic Beta-cells either:
Fail to produce adequate insulin to balance blood glucose.
Insulin resistance in skeletal ms, fat & liver.
TX:
diet, exercise,
oral medication & insulin injections.
"Diabesity": the Epidemic
Metabolic syndrome
: "cluster of pathophysiological conditions related to insulin resistance."
Abdominal obesity
Hypertriglyceridemia
Low HDL cholesterol
Elevated BP
Hyperglycemia
The world's most common dz, still increasing worldwide.
CDC:
2014 estimates 29.1 million people have diabetes (9.3% of population), 8 million undiagnosed or prediabetic.
WHO:

adults living with diabetes has quadrupled in 35 years with the Western Pacific regions worst affected (includes China & Japan).
2014: 422 million (1980: 108 million); 8.5% of world's adults
2012: dz directly caused 1.5 million deaths (additional 2.2 million deaths linked to elevated blood glucose levels.)
World cost: exceeding $827 billion.
http://www.diabetes.org/diabetes-basics/statistics/
http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
http://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf
http://www.who.int/mediacentre/factsheets/fs312/en/
http://www.genomenewsnetwork.org/articles/01_01/Diabesity.shtml
Cost of Diabetes: American Diabetes Association
2012 - US spent $245 billion in diagnosed cases with average medical expenses 2.3 times higher vs non-diabetic population.
Health Consequences of Diabetes

Microvascular
:
damage of small blood vessels
Retinopathy
- leading cause of new cases of blindness in US

Nephropathy
- renal failure (dialysis or kidney transplant)
2008 - 44% of new kidney failure cases related to diabetes

Neuropathy
- peripheral nerve damage causing decreased sensation, occurs in 60-70% of diabetic population
Non-healing plantar ulceration - 60% of nontraumatic lower limb amputations due to diabetes

Macrovascular
: damage of large blood vessels, results in CVD
Coronary Heart Dz
Stroke
PVD with arthreliosclerosis

American Diabetes Association:
2007: Diabetes listed on death certificates as contributing factor in 231,404 deaths
Adults with diabetes have 2 to 4 times higher chance of heart dz death rates
Adults with diabetes have 2 to 4 time higher chance of suffering stroke

*80% of type 2 diabetic pts will die due to CVD complications
*Avg. pt with type 2 diabetes will die 5-10 years earlier
Semmes Weinstein monofilament testing - 5.07 used for protective sensation
http://www.aafp.org/afp/2005/0601/p2123.html
Charcot Arthropathy: midfoot collapse & fx
http://coachellavalleydiabetic.blogspot.com/2012/10/why-is-charcot-foot-dangerous.html
http://www.nature.com/nrendo/journal/v5/n10/fig_tab/nrendo.2009.174_F1.html
http://buccivisionblog.wordpress.com/tag/diabetic-retinopathy/
Insulin resistance:
Release adequate levels of insulin however glucose disposal impaired in skeletal ms, liver & adipose tissue.
Impaired glucose tolerance (IGT) develops despite elevated insulin.
Pancreatic Beta cell failure causes decreased insulin secretion.
Glucose Metabolism in Type 2 Diabetes
Exercise
: major role in glucose uptake in skeletal ms.
Non-diabetic
: skeletal ms. takes up glucose as fuel with glucose output matched by the liver & decreased insulin secretion by pancreatic Beta cells.
Type 2 diabetic
: findings show that those with moderate hyperglycemia & insulin resistance still demonstrate reduced glucose with moderate intensity exercise.
Increased skeletal ms glucose transport & metabolism
Improved insulin action
Increased pancreatic Beta cell activation
Insulin
: similar role in glucose uptake in skeletal ms in exercise however, acts in a distinctly different mechanism
Both Ex & Insulin result in :
Increased glucose transport.
Increased amino acid uptake.
Increased glycogen synthesis.

Diet
: weight loss for both primary & secondary tx of diabetes.
Avoid simple & refined carbs, saturated & trans fats = proinflammatory.
Increase insulin secretion & resistance, mobilize fat into blood & decrease glucose utilization.
Increase LDL, triglyceride & inflammatory adipokines, decrease HDL levels.
Increase MUFA, PUFA, omega-3 fats, complex carbs & fiber
http://beltline.org/2012/10/05/working-exercise-into-the-work-week-guest-blog/
http://whatsthatdiet.com/encyclopedia-category/vegetarian-diets/
Exercise Training in the Prevention & Tx of type 2 Diabetes
Prevention
:

2002 Knowler et al.:

Diabetes Prevention Program - RCT, persons with IGT assigned to control, metformin or diet plus ex (reduce BW by 7%, ex 150 min/wk), f/u at 2.8 year avg
Metformin reduced risk by 31%, diet plus ex reduced by 57%
2005 Laaksonen et al:
487 persons with IGT who participated in the Finnish Diabetes Prevention study
RCT of lifestyle changes for diet, weight loss & leisure-time physical activity
In 4.1 year follow-up, increased leisure-time physical activity caused up to 65% reduction in development of diabetes.
2005 Church et al.:
type 2 diabetic men with low fitness levels = higher mortality vs. high fitness level regardless of weight.
2009 Kokkinos et al.
: type 2 diabetic men with higher cardiorespiratory fitness levels have lower mortality rates.
Each 1-MET increase in fitness yielded 14% lower mortality risk in African American men & 19% in Caucasian men.
Treatment:
Elevated insulin-stimulated glucose disposal will disappear after 5-6 days of inactivity, need regular ex program
Improvements noted at the macrovascular levels - decreased artherosclerosis & CVD
ACSM recommendations
: ex program for type 2 diabetes must be individualized taking into account severity & medication schedule
Contraindications:
illness or infection, active retinal hemorrhage, blood glucose above 250 my/dl or lower than 70 mg/dl
Ex precautions:
keep carbs on hand (not fatty), consume adequate fluids, practice good foot care, carry medical identification
Resistance Training:
moderate-high intensity circuit training has been shown to be effective however should be used in conjunction with cardiovascular program.
Treat persons with type 2 diabetes as if they have CAD!!
http://4pack.wordpress.com/2009/07/14/brain-fitness-is-found-to-be-benefitted-by-aerobic-exercise-in-the-elderly/
Clinical Considerations for Type 2 Diabetes
Always have a glucometer on hand
Ask your patient to bring their own and/or check his sugar prior to therapy

Be aware of the patient's history:
"How well do you control your diabetes?"
"How often does your sugar get low or high during the week?"
"What are your sx when your sugar gets low or high?"

Check the feet - you'd be surprised!
Diabetic shoe wear & full contact inserts are typically covered under Medicare regulations & should be replaced yearly
Instruct patient to check their feet daily
Teach them the signs of infection & warning signs
http://universalhealthcarela.com/photo-of-diabetes-symptoms-feet/
References
Bouchard, C. et.al. (2012). Physical Activity, Fitness and Obesity & Physical Activity, Fitness and Diabetes Mellitus. In Physical Activity and Health: 2nd Edition. (pp. 197-214 and 215-229). Champaign, IL: Human Kinetics.

Durstine, J.L. et.al. (2009). Diabetes & Obesity. In ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities: 3rd Edition. (pp. 182-191 and 192-200). Champaign, IL: Human Kinetics.

Goodman and Snyder. (2000). Overview of Endocrine and Metabolic Signs and Symptoms. In Differential Diagnosis in Physical Therapy: 3rd Edition. (pp. 287-333). Philadelphia, PA: W.B. Saunders Co.

Roitman and LaFontaine. (2012). The Exercising Professional's Guide to Optimizing Health: strategies for preventing and reducing chronic disease. (pp.133-155 and 156-180). Baltimore, MD: Lippincott Williams & Wilkins.
Rebecca Irby, PT, DPT, OCS
rebecca.irbyDPT@gmail.com
Premise Health @ B&W PT Clinic
434-522-6748
Premise Health Care @ BWXT in Lynchburg, Va
Purpose: to create onsite health care clinics to treat employees at the place where they work
Benefits:
Lowers health care cost to both the employer & employee.
Convenient with less time spent away from work traveling to/from health appointments.
Better compliance with annual wellness care & updated vacinations,
Improved ability to monitor long-term health conditions.
Focus on preventative medicine, ergonomics and treatment during the acute/subacute phase.

For more info or to check out job postings visit www.premisehealth.org
Location, Location, Location
http://www.cancer.org/cancer/cancercauses/dietandphysicalactivity/bodyweightandcancerrisk/body-weight-and-cancer-risk-effects
"The Biggest Loser"
"Extreme weight loss"
Trainers Chris & Heidi Powell help extremely obese individuals change lifestyle over the course of one year
Incentive to loose a certain amount of body weight in order to receive skin removal surgery
"My diet is better than yours"
Led by Shaun T. - each contestant picks a trainer & type of diet they believe will best suit their lifestyle
Trainers (not contestants) are eliminated to pick a "better" dietary plan.
Sign of the times: we are what we watch
Sign of the times: we are what we eat
Full transcript