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Slide Notes
Prescribing exercise
Presented by Dr Sheila Cook, Director of Diabetes, Endrocronologist, Toowoomba Hospital.
Aims of presentation
To assist resident medical officers in providing health and fitness advice for their patients.
Understanding the benefits of physical exercise in combating chronic - heart disease, stroke, diabetes and cancers
Presented by Dr Sheila Cook, Director of Diabetes, Endrocronologist, Toowoomba Hospital.
Aims of presentation
To assist resident medical officers in providing health and fitness advice for their patients.
Understanding the benefits of physical exercise in combating chronic - heart disease, stroke, diabetes and cancers
Prescribing exercise
Published on Jun 27, 2017
Prescribing physical exercise for your patients
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Let's get physical
Prescribing exercise for our patients
Prescribing exercise
Presented by Dr Sheila Cook, Director of Diabetes, Endrocronologist, Toowoomba Hospital.
Aims of presentation
To assist resident medical officers in providing health and fitness advice for their patients.
Understanding the benefits of physical exercise in combating chronic - heart disease, stroke, diabetes and cancers
Presented by Dr Sheila Cook, Director of Diabetes, Endrocronologist, Toowoomba Hospital.
Aims of presentation
To assist resident medical officers in providing health and fitness advice for their patients.
Understanding the benefits of physical exercise in combating chronic - heart disease, stroke, diabetes and cancers
Photo by PICS FROM THE YESTERLAND
Sitting is killing you
The truth about sitting down
Physical inactivity is bad for you
4th leading cause of death due to chronic disease worldwide: heart disease, stroke, diabetes and cancers
>3 million preventable deaths annually (6% of deaths globally)
Main cause for:
21–25% of breast and colon cancers
27% of diabetes
30% of ischaemic heart disease burden
2nd greatest contributor to the cancer burden in Australia (after smoking)
Source: Global Health Risks: mortality ad burden of disease attributable to selected major risks. World Health Organization, 2009
4th leading cause of death due to chronic disease worldwide: heart disease, stroke, diabetes and cancers
>3 million preventable deaths annually (6% of deaths globally)
Main cause for:
21–25% of breast and colon cancers
27% of diabetes
30% of ischaemic heart disease burden
2nd greatest contributor to the cancer burden in Australia (after smoking)
Source: Global Health Risks: mortality ad burden of disease attributable to selected major risks. World Health Organization, 2009
Photo by monkeyc.net
Sedentary adults
70% of Australian adults have low levels of physical activty
70% of Australian adults have low levels of physical activity = 12 million adults
Prolonged sitting is an independent risk factor for:
- Type 2 DM
- Obesity
- Cardiovascular disease
- Cancer – breast, bowel, endometrial, ovarian
Mortality
Source: Australian Bureau of Statistics (ABS) 2013 - Australian Health Survey: Physical Activity, 2011-12.
Biswas A et al Sedentary Time and Its Association with Risk for Disease Incidence, Mortality & Hospitalization in Adults, Ann Intern Med 2015: 162:123-32
Prolonged sitting is an independent risk factor for:
- Type 2 DM
- Obesity
- Cardiovascular disease
- Cancer – breast, bowel, endometrial, ovarian
Mortality
Source: Australian Bureau of Statistics (ABS) 2013 - Australian Health Survey: Physical Activity, 2011-12.
Biswas A et al Sedentary Time and Its Association with Risk for Disease Incidence, Mortality & Hospitalization in Adults, Ann Intern Med 2015: 162:123-32
Photo by RubyGoes
Sedentary adults
are in your clinic
Social disadvantage
Poor health status on self reports
Obese
Smokers
Sitting jobs - clerical or administrative work spent average 22 hours a week sitting
Watching TV (particularly in older groups)
Computer use
Source Australian Bureau of Statistice (ABS) 2013 Australian Health Survey Physical Activity, 2011-2012
Poor health status on self reports
Obese
Smokers
Sitting jobs - clerical or administrative work spent average 22 hours a week sitting
Watching TV (particularly in older groups)
Computer use
Source Australian Bureau of Statistice (ABS) 2013 Australian Health Survey Physical Activity, 2011-2012
Photo by Community Eye Health
ADA guidelines for physical activity
Difficult for patients to achieve
Guidelines:
150 minutes of moderate to vigorous exercise per week
- at 3 days per week
In Australia:
60% adults fail to achieve this
1 in 3 children exercise 60 minutes a day
1 in 10 adolescents exercise 60 minutes a day
150 minutes of moderate to vigorous exercise per week
- at 3 days per week
In Australia:
60% adults fail to achieve this
1 in 3 children exercise 60 minutes a day
1 in 10 adolescents exercise 60 minutes a day
Photo by Jem Sternhall
Revised ADA guidelines
November 2016
All adults, particularly those with type 2 diabetes, should decrease the amount of time spent in daily sendentary behaviour
Prolong sitting should be interrupted with bouts of light activity every 30 minutes (eg 3 minutes of walking, leg extensions or overhead arm stretches)
Both aerobic and resistance exercise training
are recommended for glycaemic and health outcomes
Source: Colberg Sr Sigal Rj, Yardly JE et al, Physical/exercise and diabetes - A Position Statement of the American Diabetes Association.
Diabetes Care 2016 Nov; 39(11): 2065-2079. https://doi.org/10.2337/dc16-1728
Prolong sitting should be interrupted with bouts of light activity every 30 minutes (eg 3 minutes of walking, leg extensions or overhead arm stretches)
Both aerobic and resistance exercise training
are recommended for glycaemic and health outcomes
Source: Colberg Sr Sigal Rj, Yardly JE et al, Physical/exercise and diabetes - A Position Statement of the American Diabetes Association.
Diabetes Care 2016 Nov; 39(11): 2065-2079. https://doi.org/10.2337/dc16-1728
Photo by tanakawho
Exercise: light intensity (3METs)
- Sleeping: 0.9
- Watching tv: 1.0
- Computer/desk work: 1.5
- Walking the dog 2.3 - 2.9
Exercise: moderate intensity (3-6METs)
- Exercise bike: 3.0-6.0
- Brisk walking 4-5kms: 3.3
- Aerobics (light/mod): 3.5
- Rec cycling 4.0 - 5.5
- Sex: 4 - 5.8
Exercise: vigorous intensity (3-6METs)
- Running up stairs: 6.5- 7.5
- Jogging 7.0
- Push ups burpees: 8.5
- Running 8.0
- Jumping rope: 10.0
Resistance vs aerobic
Aerobic exercise doesn't improve efficiency of muscles
Resistance training builds up strength more effectively
Muscles develop strength rapidly, even if only a few times a day
Metabolic benefits take
Type 2 Diabetes is characterized by:
Accelerated loss of skeletal muscle
Reduced strength
Reduced numbers and function of mitochondria.
Resistance training is better matched to T2DM than endurance training
Resistance training builds up strength more effectively
Muscles develop strength rapidly, even if only a few times a day
Metabolic benefits take
Type 2 Diabetes is characterized by:
Accelerated loss of skeletal muscle
Reduced strength
Reduced numbers and function of mitochondria.
Resistance training is better matched to T2DM than endurance training
Photo by gruntzooki
c
Mitochondria - the cell's power house
Exercise improves lipid profile,
Improves insulin senstivity| reduces glucose & HbA1c
Mitochondria - the cell's power house
Activate mitochondria
Muscle strength |Energy generation
↑Muscle strength & function
↑Cardiovascular fitness
↓Visceral adipose & inflammation
Improved hepatic function
Improved lipid profile
↓insulin resistance
↑Basal metabolic rate
↑Cardiovascular fitness
↓Visceral adipose & inflammation
Improved hepatic function
Improved lipid profile
↓insulin resistance
↑Basal metabolic rate
Photo by Helgi Halldórsson/Freddi
Exercise
Improves endothelial function
Improved systemic perfusion
↑ cardiovascular fitness
↑ cerebral circulation
↑ renal perfusion
↑Peripheral vascular networks
↑capillary density (muscle, skin)
↑ cardiovascular fitness
↑ cerebral circulation
↑ renal perfusion
↑Peripheral vascular networks
↑capillary density (muscle, skin)
Photo by Lars Plougmann
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Improved systemic perfusion
↑ cardiovascular fitness
↑ cerebral circulation
↑ renal perfusion
↑Peripheral vascular networks
↑capillary density (muscle, skin)
↑ cardiovascular fitness
↑ cerebral circulation
↑ renal perfusion
↑Peripheral vascular networks
↑capillary density (muscle, skin)
Untitled Slide
Back to your waiting room
Social disadvantage
Poor health status on self reports
Obese
Smokers
Sitting jobs - clerical or administrative work spent average 22 hours a week sitting
Watching TV (particularly in older groups)
Computer use
Source Australian Bureau of Statistics (ABS) 2013 Australian Health Survey Physical Activity, 2011-2012
Poor health status on self reports
Obese
Smokers
Sitting jobs - clerical or administrative work spent average 22 hours a week sitting
Watching TV (particularly in older groups)
Computer use
Source Australian Bureau of Statistics (ABS) 2013 Australian Health Survey Physical Activity, 2011-2012
Photo by Community Eye Health
who has never done exercise
How to approach the patient
New diagnosis T2DM
HbA1c 8.2%
Has never done exercise and unlikely to start.
How do you motivate him?
What is the minimum prescription that will confer benefit?
Interrupt prolonged sitting - standing is better than sitting
Resistance training is better than light intensity exercise
Appeal to his youth - played sport?
HbA1c 8.2%
Has never done exercise and unlikely to start.
How do you motivate him?
What is the minimum prescription that will confer benefit?
Interrupt prolonged sitting - standing is better than sitting
Resistance training is better than light intensity exercise
Appeal to his youth - played sport?
Photo by Tobyotter
Breaking prolonged sitting with 5 mins standing or low intensity walking reduces post-prandial glucose, insulin and lipids in pre-diabetes and Type 2 Diabetes. Improved glucose levels persist in the next day
New diagnosis T2DM
HbA1c 8.2%
Has never done exercise and unlikely to start.
How do you motivate him?
What is the minimum prescription that will confer benefit?
Interrupt prolonged sitting
Resistance training is better than light intensity exercise
Source:
Henson J et al. Breaking up Prolonged Sitting with Standing or Walking attenuates the postprandial metabolic response in Postmenopausal Women: A Randomized Acute Study. Diabetes Care 2016; 39: 130-138
HbA1c 8.2%
Has never done exercise and unlikely to start.
How do you motivate him?
What is the minimum prescription that will confer benefit?
Interrupt prolonged sitting
Resistance training is better than light intensity exercise
Source:
Henson J et al. Breaking up Prolonged Sitting with Standing or Walking attenuates the postprandial metabolic response in Postmenopausal Women: A Randomized Acute Study. Diabetes Care 2016; 39: 130-138
Photo by Tobyotter
A standing desk improves glucose levels by 43% compared with seated computer desk
Source:
Buckley JP et al. Standing-based office work shows encouraging signs of attenuating postprandial glycaemic excursion. Occup Environ Med 2014; 71: 2053 - 61
Buckley JP et al. Standing-based office work shows encouraging signs of attenuating postprandial glycaemic excursion. Occup Environ Med 2014; 71: 2053 - 61
Photo by The Shifted Librarian
who is walking 30 mins every day
How to approach the patient
T2DM for 6 years
HbA1c 8.1%
Your patient is going for 30 minute walks every day, but is frustrated:
She is following the exercise recommendations
Walking her dog 30 minutes every day
No weight loss
HbA1c is rising 8.1%
Recommendation:
Resistence training
Before breakfast or after meals
High intensity interval training
Improve post-meal BGLs
HbA1c 8.1%
Your patient is going for 30 minute walks every day, but is frustrated:
She is following the exercise recommendations
Walking her dog 30 minutes every day
No weight loss
HbA1c is rising 8.1%
Recommendation:
Resistence training
Before breakfast or after meals
High intensity interval training
Improve post-meal BGLs
Photo by Bev Goodwin
Tabata
Photo by Joint Base Lewis McChord
Untitled Slide
Untitled Slide
Photo by licornenoir
Interval training
Bursts of moderate-high intensity exercise interspersed with short periods of rest
20 seconds on & 10 seconds off
60 seconds on & 60 seconds off
Cardiovascular fitness & metabolic benefits are achieved in 90% less time than aerobic exercise
Activity period
Mitochondria are activated
Moderate >> light exercise
Relaxation period = mRNA transcription
Increased muscle efficiency
Improved insulin sensitivity
Lack of fatigue better adherence
20 seconds on & 10 seconds off
60 seconds on & 60 seconds off
Cardiovascular fitness & metabolic benefits are achieved in 90% less time than aerobic exercise
Activity period
Mitochondria are activated
Moderate >> light exercise
Relaxation period = mRNA transcription
Increased muscle efficiency
Improved insulin sensitivity
Lack of fatigue better adherence
Photo by crmgucd
can't do exercise
How to approach the patient who
T2DM with PVD & CCF
HbA1c 8.3%
Can't do exercise
Peripheral vascular disease & CCF
Scared to exercise
Recommend resistance training
-> Muscle strengthening
Prescribe 3 sets of 6 contractions (>50% of maximum), three times / week
Maximum strength achieved in 6-8 weeks
Improved endothelial function
Improve “inactive” skeletal muscle circulation
Upper limb exercise lower limb benefits
HbA1c 8.3%
Can't do exercise
Peripheral vascular disease & CCF
Scared to exercise
Recommend resistance training
-> Muscle strengthening
Prescribe 3 sets of 6 contractions (>50% of maximum), three times / week
Maximum strength achieved in 6-8 weeks
Improved endothelial function
Improve “inactive” skeletal muscle circulation
Upper limb exercise lower limb benefits
Photo by tomhe
frightened of hypo's
How to approach the patient who is
Patient with Type 1 Diabetes HbA1c 8.0%
Too frightened of hypo's so avoids exercise
60% of people with Type 1 Diabetes don’t exercise
We should encourage exercise…
60% are overweight or obese
40% are hypertensive
60% dyslipidaemic
Cardiovascular disease is the leading cause of death (2-3 fold higher than T2DM)
Source: Bohn et al 2015 Diabetes Care; 38:1536-43
McCarthy et al 2016 Prev Med; 91: 138-43
Too frightened of hypo's so avoids exercise
60% of people with Type 1 Diabetes don’t exercise
We should encourage exercise…
60% are overweight or obese
40% are hypertensive
60% dyslipidaemic
Cardiovascular disease is the leading cause of death (2-3 fold higher than T2DM)
Source: Bohn et al 2015 Diabetes Care; 38:1536-43
McCarthy et al 2016 Prev Med; 91: 138-43
Photo by TheChanel
Kylie wants to bike ride
Aerobic exercise:
↑glucose uptake in muscles independent of insulin (50x)
↑glucagon & ↓insulin to drive hepatic glucose production
Carbohydrate is the preferred energy source
Hypoglycaemia develops within 45 minutes of starting exercise
More likely if exercise in afternoon
More likely if exercise within 2-3 hours of bolus insulin
Post-exercise hypoglycaemia
More likely if afternoon exercise
↑risk persists for 24 hours
↑glucose uptake in muscles independent of insulin (50x)
↑glucagon & ↓insulin to drive hepatic glucose production
Carbohydrate is the preferred energy source
Hypoglycaemia develops within 45 minutes of starting exercise
More likely if exercise in afternoon
More likely if exercise within 2-3 hours of bolus insulin
Post-exercise hypoglycaemia
More likely if afternoon exercise
↑risk persists for 24 hours
Photo by mzec
