Harnessing the Power of Exercise Program Overview to Prevent Type-2 Diabetes Gary Scheiner MS, CDE T2D Risks Factors Owner/Clinical Director Physical Activity Benefits Integrated Diabetes Services LLC gary@integrateddiabetes.com Increasing General Daily Activity (610) 642-6055 Designing an Exercise Prescription Practice! Risk Factors for T2D Risk Factors for T2D Overweight/obesity Overweight/obesity Age 45 or older Age 45 or older Family history of diabetes Family history of diabetes African American, Native American, Asian American, Hispanic, Pacific African American, Native American, Asian American, Islander Hispanic, Pacific Islander Hypertension Hypertension Low HDL or High triglycerides Low HDL or High triglycerides History of GDM (or baby weighing 9 lbs) History of GDM (or baby weighing 9 lbs) Low levels of physical activity Low levels of physical activity PCOS PCOS History of heart disease or stroke History of heart disease or stroke History of depression History of depression Source: NIDDK, US Dept of Health Source: NIDDK, US Dept of Health Acanthosis nigricans Acanthosis nigricans & Human Services & Human Services The Root Cause of Type-2 How Is Insulin Sensitivity Enhanced by Diabetes is INSULIN Physical Activity? RESISTANCE 1
Amazing Medicine Health Concern Effect of Physical Activity Insulin Sensitivity Insulin Resistance Receptor Proliferation GLUT-4 Transport* Postprandial Slower CHO Absorption Glucose Utilization Hyperglycemia Accelerated insulin action Need for Insulin/Meds Acute & Chronic Reduction *Am J Physiol Endocrinol Metab 277: E733-E741, 1999 Amazing Medicine Amazing Medicine Health Concern Effect of Physical Activity Health Concern Effect of Physical Activity Heart Disease Collateral Circulation Atherosclerosis Disuse Syndrome/ Conditioning Gains Adhesive Capsulitis Flexibility/ROM LDL, HDL Blood Lipids Work Capacity Triglycerides Stress Tension Release Diastolic BP Hypertension More Restful Sleep Obesity Calorie Burning Depression Self-Control, Pride Metabolism Appetite Suppression* Pain Endorphin Production *American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 2008, No. 16. Activity Recommendations Recommendations for Activity Diabetes Prevention Program: 150 minutes/ week of moderately intense activity for National Weight Control Registry: 90% of prevention of diabetes members engage in daily physical activity for ACSM: 30 minutes, 5 days/week of moderately an average of 60 to 75 minutes at a moderate intense activity and 2 to 3 days of resistance level of intensity training a week for cardiovascular health Avg 11,000 to 12,000 steps a day Look AHEAD: 175 minutes/week of moderately intense activity increased gradually to 200 minutes Wyatt HR et al. Lessons from patients who have successfully maintained weight loss. Obesity Management. April 2005: 56 to 61 Catenacci VA et al. Physical activity patterns in the NWCR. Obesity. 2008; 16: 153 to 158 2
The Value of General Daily Activity Burns Calories Maintains Functional Capacity Raises Metabolism Instills an “Attitude” Percentage reduction in initial weight at 1 year based on quartile of average weekly minutes of self-reported physical activity. The number within each bar shows the mean number of weekly minutes of physical activity. Wadden et al. One Year Weight Losses in the Look AHEAD Study: Factors Associated with Success. Obesity 2009; 17:713-722. General Daily Activity General Daily Activity Ideas for Increasing Walking Ideas for Increasing Walking (Consider using a pedometer or phone app for step counts!) – Walk on moving walkways rather than standing – Walk while talking on phone – Search out the furthest parking spots – When meeting with friends, walk rather than sitting – Go down every aisle in grocery stores – Take 1-2 flights of stairs instead of elevators & – Get a dog and walk him two or three times a day escalators – Walk slowly on a treadmill while watching TV – Walk (rather than drive) to errands near home General Daily Activity General Daily Activity Other ideas for increasing energy Other ideas for increasing energy expenditure expenditure – Do your own gardening and yard work – Hide the remote! Change channels manually – Do your own house work – Take up carpentry or sculpting – Go out on “active” dates: dancing, bowling, – Practice yoga, pilates or Tai-Chi skating, mini golf – Take dance lessons – Ride a bike to complete local errands 3
Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care Grandes, et al. Arch Intern Med 2009; 169(7): 694 ‐ 701 “Exercise” Work/Leisure Activity vs Randomized Challenging, Uses Often discontinuous, Controlled Large Muscle Groups, varied intensity, less Rhythmic or challengingMay not be Multi ‐ Center Continuous, Over a very challenging Blinded Analysis Period of Time Still provides benefits! Significant conditioning, strengthening, metabolic benefits Effectiveness of Physical Activity Advice and Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care Prescription by Physicians in Primary Care Control Advice ‐ Only Advice + Prescription 6-MONTH OUTCOMES Provider Provider Training Same as advice group, + Training Incr. in moderate / Incr. In moderate / Used Web software re: Goal setting Standard Care benefits, risks, general vigorous activity vigorous activity Barriers addressed activity suggestions (min/wk) (MET h/wk) 3 ‐ month Plan Summary pamphlet Control 31.3 2.05 Printed exercise Rx (mode, freq., duration, intensity, progression) Advice Only 36.4 2.41 Self ‐ monitoring log Advice + 79.7* 5.49* N=2069 N=1565 N=683 Prescription MDs=27 MDs=29 MDs=29 *p<.01 Designing a Physical Activity Physical Activity Rx Prescription for Preventing T2D Mode Mode/Type Examples: Large Muscle Groups Duration Brisk Walking Continuous or Cycling Intensity Rhythmic Swimming Frequency Rowing Low ‐ Impact (if high Progression Stair Climbing/EFX risk of injury) Aerobics Classes/Videos Cross Train to prevent Court Sports overuse injuries/burnout Strength Training 4
Strength Training Benefits Strength Training Principles Metabolism Warm ‐ Up First Insulin sensitivity/glucose 2 ‐ 3 sets of 10 ‐ 15 reps disposal Work large muscle groups first Immediate caloric expenditure Exhale w/exertion; no valsalva Improve/maintain functional Progress reps, then wt in capacity small increments Self ‐ image, confidence Only wt if technique is sound Allow 48 hr recovery Exercise Rx “Line Item”: Exercise Rx “Line Item”: Duration Intensity 30-60 Minutes Generally Recommended Longer duration preferred for weight loss May be broken into a few shorter sessions (for weight loss) Include 2-5 Minute Warm-Up/Cool-Down Add Stretching After Workout Exercise Rx “Line Item”: Exercise Rx “Line Item”: Intensity Frequency Most (if not all) days of the week 55% - 90% of Maximal Heart Rate Think of exercise as medicine RPE of “Fairly Light” (beginners) to “Hard” Cross Train to Prevent Overuse Injuries (experienced exercisers) and Burnout Able to talk, but not sing Insulin sensitivity lost after 24-72 hrs 5
Physical Activity Rx Activity Levels Affect Insulin Progression Sensitivity PROFOUNDLY! SET UP TO SUCCEED! Beginners: Start with low intensity, short duration Build duration first, then increase intensity and frequency Add new activities as conditioning permits Progression Through Interval Training Time For YOU to Be the Physical Activity Wk 1: 9 min light, 1 min hard (x3=30 min) Specialist! Wk 2: 8 min light, 2 min hard (x3=30 min) Wk 3: 7 min light, 3 min hard (x3=30 min) Wk 4: 6 min light, 4 min hard (x3=30 min) Etc… Betty Bloodsugar Thank You for Prescribing • 55 Year old female, 280 lbs (150 kg). • Lives in inner ‐ city; works at mall as a cashier. Also Physical Activity! tends to 4 grandkids. • Dad and sister have T2D. PCP told her she needs to lose weight. • Has an old stationary bike, uses it to hang/dry clothes. • Social butterfly. 6
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