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Exercise Exercise && DiabetesDiabetes MellitusMellitusAbdulrahman Mohammed AL-Abdulrahman Mohammed AL-

HowikanHowikan

Director of Cardiopulmonary Exercise Testing Director of Cardiopulmonary Exercise Testing And pulmonary function test Lab, Medicine dep., And pulmonary function test Lab, Medicine dep.,

College of MedicineCollege of Medicine

King kalied university hospitalKing kalied university hospital Diabetes Educator Course, KA Med City, April 2007Diabetes Educator Course, KA Med City, April 2007

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DefinitionsDefinitions

Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state.

Physical ActivityPhysical Activity

Physical FitnessPhysical Fitness

A set of attributes that people have or achieve, which relates to the ability to perform physical activity.

Caspersen, et al., Public health Rep,1985

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DefinitionsDefinitions

The amount of energy expended during exercise relative to the energy expenditure during rest.

Metabolic Equivalent (MET)Metabolic Equivalent (MET)

Energy expenditure during rest = 1 MET = 3.5 ml of O2 / kg. min = 1 kcal / kg. hr

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Classification of Exercise Classification of Exercise

Aerobic exercise: Endurance type exercise, rhythmic,

sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc…

Strength (Resistance) exercise: Weight training with free weight,

machine, elastic rope, calisthenics, etc…

Flexibility exercise: Stretching exercise.

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PhysicalPhysical Activity Intensity in MET Activity Intensity in MET

Light: Less than 3 MET

Moderate: 3 – 6 MET

Vigorous: Above 6 MET

CDC, 1996

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Moderate & Vigorous IntensityModerate & Vigorous Intensity Physical Activities Physical Activities

Moderate: Brisk walking, Recreational swimming,

Volleyball, Slow aerobics, Moderate cycling Gardening, Tennis-double, Badminton etc..

Vigorous: Jogging, Running, Tennis-single, Basketball,

Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Soccer, etc

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What is the Amount of Physical ActivityWhat is the Amount of Physical Activity that Promotes Health?that Promotes Health?

Moderate Intensity Physical Activity. Energy Expenditure = 3 - 6 MET That is: ≥ 30 min/day, ≥ 5 days/week. 150 min. per week. ACSM, 2000; CDC, 1996

≥ 1000 k. calories/week. Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000

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Health-Related Dimensions of Physical ActivityHealth-Related Dimensions of Physical Activity

للصحة المعزز البدني النشاط أبعاد Health-Related Dimensions of Physical ActivityHealth-Related Dimensions of Physical Activity

للصحة المعزز البدني النشاط أبعاد

المصروفة • المصروفة الطاقة Caloric Caloric((الطاقةExpenditureExpenditure((.. الشدة • المرتفعة الهوائية الشدة األنشطة المرتفعة الهوائية األنشطة

))Aerobic Intensity((..العضلية • العضلية القوة ..))Muscular Strength((القوة

..)) Flexibility((المرونة المرونة •

حمل • فيها يتم التي البدنية حمل األنشطة فيها يتم التي البدنية األنشطةالجسم الجسم

))Weight-bearing physical activity((..

Caspersen, et al., 1998

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Exercise Exercise & & Diabetes Diabetes

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Can Exercise PreventCan Exercise Prevent

or or Delay DiabetesDelay Diabetes ??

Evidences fromEvidences from Randomized Clinical TrialsRandomized Clinical Trials

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Exercise in the Prevention of DiabetesExercise in the Prevention of Diabetes

Malmo Study

Sweden

260 males(6 yrs)

Eriksson & Lindgarde,Eriksson & Lindgarde, Diabetologia, Diabetologia, 1999119991

Da Qing, China China 577 males & Females (6 yrs)

Pan, et al,Pan, et al, Diabetes Care, Diabetes Care, 19971997

The Nurse’s Health Study

USA 70,000Nurses (8 yrs)

Hu, et alHu, et al,.,.

JAMA, JAMA, 19991999

Finnish Experimental Study

Finland 523 males& Females (4 yrs)

Tuomilehto, et al.,Tuomilehto, et al., N N Engl J Med, Engl J Med, 20012001

Diabetes Prevention Study

USA 3234 males & Females (3 yrs)

Diabetes Prev. Program Diabetes Prev. Program Research GroupResearch Group,, N Engl J Med, N Engl J Med, 20022002

Participants are either normal or have Participants are either normal or have ++ GTT GTT

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Moderate Physical Activity Moderate Physical Activity Performed Regularly for 120 – 200 Performed Regularly for 120 – 200

min. per week Reduces the min. per week Reduces the Incidence of Diabetes in People Incidence of Diabetes in People

Predisposed to DiabetesPredisposed to Diabetes..

Exercise in the Prevention of diabetesExercise in the Prevention of diabetesSummary of the ResultsSummary of the Results

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Exercise Exercise in the in the Management of Management of

DiabetesDiabetes

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Exercise & Type 1 DiabetesExercise & Type 1 Diabetes

Improves physical fitness.Improves physical fitness.

Increases self confidence.Increases self confidence.

Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.

It has no direct effect on glucose control.It has no direct effect on glucose control.

Proper timing of Exercise & Insulin.Proper timing of Exercise & Insulin.

Avoid strenuous exercise before bed time. Avoid strenuous exercise before bed time.

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Exercise & Type 2 DiabetesExercise & Type 2 Diabetes

Improves physical fitness & reduces fat %.Improves physical fitness & reduces fat %.

Increases self confidence.Increases self confidence.

Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.

Improves glucose control:Improves glucose control:

Improving insulin sensitivity.Improving insulin sensitivity. Increasing Glu T4Increasing Glu T4 (glucose transporters).(glucose transporters).

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Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 Diabetics

0

5

10

15

20

0 30 60 90 120 150 180

Before After

Pla

sma

Glu

cose

Pla

sma

Glu

cose

(m

mo

l/l)

(mm

ol/l

)

Time Time (min)(min)

12 months of Training12 months of Training

Holloszy, et al. Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-65 1986, 711: 55-65

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Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 Diabetics

0

400

800

1200

1600

0 30 60 90 120 150 180

Before After Pla

sma

Insu

linP

lasm

a In

sulin

(p

mo

l/l)

(pm

ol/l

)

Time Time (min)(min)

12 months of Training12 months of Training

Holloszy, et al. Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-65 1986, 711: 55-65

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Exercise Exercise Prescription Prescription for Diabetic for Diabetic

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Exercise Prescription for DiabeticExercise Prescription for Diabetic 1/41/4

Aerobic activity for 30 Aerobic activity for 30 min.min. extended extended (gradually)(gradually) to 60 to 60 min.min. every day or most days/week. every day or most days/week.

HR during activity should be gradually HR during activity should be gradually increased to reach 60 – 70% of HR max.increased to reach 60 – 70% of HR max.

Exercise session should include 5-10 min. of Exercise session should include 5-10 min. of warm-up and a 5 min of cool-down.warm-up and a 5 min of cool-down.

Exercise must involve most major muscles in Exercise must involve most major muscles in both lower and upper parts of the body.both lower and upper parts of the body.

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Exercise Prescription for DiabeticExercise Prescription for Diabetic 2/42/4

Moderate intensity weight training program Moderate intensity weight training program is recommended to maintain muscle strength is recommended to maintain muscle strength

( 8-12 repetitions 2 times /week).( 8-12 repetitions 2 times /week).

Exercise must be regular. Benefits are Exercise must be regular. Benefits are diminished after 1 -2 weeks of stopping .diminished after 1 -2 weeks of stopping .

For those with feet problems, avoid running.For those with feet problems, avoid running. Alternate between walking, swimming, and cycling.Alternate between walking, swimming, and cycling.

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Exercise Prescription for DiabeticExercise Prescription for Diabetic 3/43/4

When using insulin, avoid exercise if glucose When using insulin, avoid exercise if glucose levels below 100 mg/dl or above 250 mg/dl.levels below 100 mg/dl or above 250 mg/dl.

Use proper shoes, with silica gel or air-filled Use proper shoes, with silica gel or air-filled soles, and always keep feet dry. soles, and always keep feet dry.

Avoid dehydration by keeping your body Avoid dehydration by keeping your body always hydratedalways hydrated..

Do not inject insulin into a body part that is Do not inject insulin into a body part that is expected to be used during exercise.expected to be used during exercise.

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Graded Exercise Testing for DiabeticGraded Exercise Testing for Diabetic 4/44/4

It is recommended before any moderate to It is recommended before any moderate to high intensity exercise, especially if:high intensity exercise, especially if:

Age is > 35 yrs.Age is > 35 yrs. Type 2 diabetes for > 10 yrs duration.Type 2 diabetes for > 10 yrs duration. Type 1 diabetes for > 15 yrs duration.Type 1 diabetes for > 15 yrs duration. Presence of any CHD risk factors.Presence of any CHD risk factors. Presence of microvascular diseasePresence of microvascular disease (retinopathy, nephropathy).(retinopathy, nephropathy). Presence of peripheral vascular disease.Presence of peripheral vascular disease.

ADA Position Statement, Diabetes Care, 2002ADA Position Statement, Diabetes Care, 2002

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Exercise Exercise Prescription for Prescription for Special Cases Special Cases

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Diabetic with Diabetic with Peripheral NeuropathyPeripheral Neuropathy

Repetitive exercise on insensitive feet can Repetitive exercise on insensitive feet can lead to ulceration & fractureslead to ulceration & fractures..

Peripheral neuropathy may results in loss Peripheral neuropathy may results in loss of sensation in the feet.of sensation in the feet.

Limit weight-bearing exerciseLimit weight-bearing exercise (Treadmill, (Treadmill, Prolonged walking, Jogging, Step exercise, etc..) Prolonged walking, Jogging, Step exercise, etc..)

Use proper shoes, and always monitor the feetUse proper shoes, and always monitor the feet..

Alternative exercises areAlternative exercises are: Swimming, : Swimming, Bicycling, Arm exercise, Chair exercise, etc..Bicycling, Arm exercise, Chair exercise, etc..

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Diabetic with Diabetic with Autonomic NeuropathyAutonomic Neuropathy

Hypotension and hypertension are more Hypotension and hypertension are more likely to develop after vigorous exercise.likely to develop after vigorous exercise.

This condition may limit exercise capacity & This condition may limit exercise capacity & increase the risk of CV event during exercise.increase the risk of CV event during exercise.

Those patients may have difficulty with Those patients may have difficulty with thermoregulation:thermoregulation:

Avoid exercise in hot or cold environments.Avoid exercise in hot or cold environments. encourage adequate hydration. encourage adequate hydration.

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Hypoglycemia during or after ExerciseHypoglycemia during or after Exercise

It will most likely occur if the patient: Takes insulin or diabetes pill. Skips a meal. Exercises for a long time. Exercises strenuously.

If it occurs, what can be done? Patient must eat a snack before exercise, or. Adjusts the medication dose. Remember: Patient should always carry a source

of CHO with him ( An apple or orange juice, or a piece of fruit).

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Energy ExpenditureEnergy Expenditureduring during

Physical Activity!Physical Activity!

ActivityActivity CaloreiCalorei

Brisk walking Brisk walking 0.070.07

RunningRunning (7.5 min per km) (7.5 min per km) 0.130.13

RunningRunning (5 min per km)(5 min per km) 0.2080.208

SwimmingSwimming 0.1620.162

Rope skippingRope skipping (70/min)(70/min) 0.1620.162

Rope skippingRope skipping (80/min)(80/min) 0.1650.165

BadmintonBadminton 0.0970.097

TennisTennis 0.1090.109

SquashSquash 0.2120.212

BasketballBasketball 0.1380.138

Energy Cost of Physical ActivityEnergy Cost of Physical Activity))kilocalorie/kg. minkilocalorie/kg. min((

McArdle, et., 1991

ActivityActivity METMET

Walking Walking (slow)(slow) 2.52.5

Walking (Walking (Brisk)Brisk) 44

RunningRunning (7.5 min per km) (7.5 min per km) 88

SwimmingSwimming 66

Rope skippingRope skipping (slow)(slow) 88

Weight trainingWeight training 66

BadmintonBadminton 4.54.5

Tennis Tennis (single)(single) 88

SquashSquash 1212

BasketballBasketball 88

Energy Cost of Physical ActivityEnergy Cost of Physical Activity))METMET((

Ainsworth, et., 2000

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How to Calculate How to Calculate Energy Expenditure Energy Expenditure during Brisk Walkingduring Brisk Walking!!

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== 0.07 0.07 k.k. caloriecalorie per kg of body weightper kg of body weight //

min.min.

Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking

An Example:An Example:

a a person weighing 76 kg would expend:person weighing 76 kg would expend:

0.070.07 X 76 = X 76 = 5.35.3 k. k. calorie per min.calorie per min.

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Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking

If he has to expend 1200 k.If he has to expend 1200 k. calories per week.calories per week.

How much time he should walk per week?How much time he should walk per week?

1200 / 5.3 = 226.4 min.1200 / 5.3 = 226.4 min.

= 45 min / 5 days per week, or= 45 min / 5 days per week, or

= 57 min / 4 days per week.= 57 min / 4 days per week.

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Case StudiesCase Studies

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Case Study 1Case Study 1 (Q)(Q)

An obese sedentary women, her age = 55 yrs, An obese sedentary women, her age = 55 yrs,

weight = 80 kg, height = 152 cm. weight = 80 kg, height = 152 cm.

Has type 2 diabetes for 6 years, and BP under Has type 2 diabetes for 6 years, and BP under

control with medication. Otherwise she is OK.control with medication. Otherwise she is OK.

Prescribe diet and physical activity to reduce her Prescribe diet and physical activity to reduce her weight as well as to control her diabetes and weight as well as to control her diabetes and hypertension, targeting energy expenditure with hypertension, targeting energy expenditure with exercise of 1600 exercise of 1600 KK.. calories per week? calories per week?

Assuming a target body wt. of 60 kg, what is her Assuming a target body wt. of 60 kg, what is her daily energy needs? daily energy needs?

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Case Study 1 Case Study 1 ((AA))

BMIBMI = 80/ (1.52 * 1.52) = = 80/ (1.52 * 1.52) = 34.634.6 kg/m kg/m22

WalkingWalking: 0.07 : 0.07 K.K. calorie/kg. mincalorie/kg. min..

Energy cost of walkingEnergy cost of walking = 80 * 0.07 = 5.6 = 80 * 0.07 = 5.6 kk cal. min.cal. min.

Time needed to expend 1600 Time needed to expend 1600 k.k. cal. Per weekcal. Per week = =

1600/ 5.6 = 285.7 1600/ 5.6 = 285.7 minutes; minutes;

285.7/5 days = 57.1285.7/5 days = 57.1 min. min.

OROR approx. 1 hour a day approx. 1 hour a day forfor 5 days per week5 days per week

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