Unleash Your Inner Exercise Expert! Gary Scheiner MS, CDE 2014 - PowerPoint PPT Presentation

Unleash Your Inner Exercise Expert! Gary Scheiner MS, CDE 2014 AADE Diabetes Educator of the Year Owner & Clinical Director, Integrated Diabetes Services LLC 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 gary@integrateddiabetes.com

Objectives  Describe the essential role physical activity plays in diabetes management  Apply strategize to minimize risks associatied with exercise in the diabetes population  Provide the tools necessary to design individualized exercise plans for patients with diabetes

Amazing Medicine Diabetes Concern Exercise Effect Heart Disease Collateral Circulation  Atherosclerosis  LDL, Triglycerides Blood Lipids  HDL  Diastolic BP Hypertension Obesity Calorie Burning  Metabolism Appetite Suppression

Amazing Medicine Diabetes Concern Exercise Effect Disuse Syndrome Conditioning Gains Adhesive Capsulitis Flexibility/ROM Work Capacity Stress Tension Release More Restful Sleep Depression Sense of Control, Pride Pain Endorphin Production

Amazing Medicine Diabetes Concern Exercise Effect  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

Primary Risks  Hypoglycemia  Worsening Hyperglycemia / DKA  Exacerbation of Existing Complications

Physical Activity Is:  CRITICAL to Diabetes Care  Potentially Risky  Requires Individualization

How Many Diabetes Clinics Have an Exercise Specialist on Staff? A. 20% B. 10% C. 5% D. <1%

What Is An Exercise Prescription?  Detailed, Specific Plan of Action  Enhances Safety  Improves Outcomes

Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care Grandes, et al. Arch Intern Med 2009; 169(7): 694-701  Randomized  Controlled  Multi-Center  Blinded Analysis

Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care Control Advice-Only Advice + Prescription  Provider  Provider Training  Same as advice group, + Training  Used Web software re:  Goal setting  Standard Care benefits, risks, general  Barriers addressed activity suggestions  3-month Plan  Summary pamphlet  Printed exercise Rx (mode, freq., duration, intensity, progression)  Self-monitoring log N=2069 N=1565 N=683 MDs=27 MDs=29 MDs=29

Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care 6-MONTH OUTCOMES Incr. in moderate / Incr. In moderate / vigorous activity vigorous activity (min/wk) (MET h/wk) Control 31.3 2.05 Advice Only 36.4 2.41 Advice + 79.7* 5.49* Prescription *p<.01

True or False? The exercise recommendations for people with diabetes are very similar to those without diabetes.

Designing an Exercise Prescription for Patients with Diabetes  Mode/Type  Duration  Intensity  Frequency*  Progression  Timing*  Adjustments* * Differences!!!  Motivation

Quality Exercise vs Work/Leisure Activity  Uses Large Muscle  Tends to be “stop & go” Groups  Intensity may be very  Rhythmic or low or very high Continuous  Duration varies  Over a Period of Time  May not be very  At Least Somewhat challenging Challenging  Still has benefits!

Exercise Rx “Line Item”: Mode Examples:  Large Muscle Groups  Brisk Walking  Continuous or  Cycling Rhythmic  Swimming  Rowing  Low-Impact (if high  Stair Climbing/EFX risk of injury)  Aerobics Classes/Videos  Cross Train to prevent  Court Sports overuse injuries/burnout  Strength Training

Strength Training Benefits  Metabolism   Insulin sensitivity/glucose disposal   Immediate caloric expenditure  Improve/maintain functional capacity  Self-image, confidence

Strength Training Principles  Warm-Up First  2-3 sets of 10-15 reps  Work large muscle groups first  Exhale w/exertion; no valsalva  Progress reps, then  wt in small increments  Only  wt if technique is sound  Allow 48 hr recovery

Exercise Rx “Line Item”: Duration  20-60 Minutes Generally Recommended  Long duration preferred for weight loss  May be broken into a few shorter sessions (for weight loss)  Include 2-5 Minute Warm-Up/Cool-Down  Stretch After Workout (after warmup if high- impact sport)

Exercise Rx “Line Item”: Intensity  55% - 90% of Predicted Maximal Heart Rate (actual maximal heart rate if stress tested)  RPE of “Fairly Light” (beginners) to “Hard” (experienced exercisers)  Able to talk, but not sing

Rating of Perceived Exertion (RPE) 1 Nothing 2 Very, Very Light 3 Very Light 4 Fairly Light 5 Somewhat Hard 6 Hard 7 Very Hard 8 Very, Very Hard Painful; Can’t Keep Up 9

Exercise Rx “Line Item”: Frequency  Think of exercise as medicine  Enhanced insulin sensitivity decays, lost completely after 24-72 hrs  Exercise most (if not all) days of the week  Do not skip more than one day

Activity Levels Affect Insulin Sensitivity PROFOUNDLY!

Exercise Rx “Line Item”: Progression  SET UP TO SUCCEED!  Beginners: Start with low intensity, short duration  Build duration first, then increase intensity  Add new activities as conditioning permits

Progression Through Interval Training  Wk 1: 9 min light, 1 min hard (x3=30 min)  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…

Exercise Rx “Line Item”: Timing  After meals (if taking mealtime insulin and weight loss desired)  After meals (to improve postprandial BG control)  Pre-Meal (w/unstable CAD, CHF)  Morning (for long-term maintenance)  Anytime it is convenient and preferred

Exercise Rx “Line Item”: Adjustments  Hypoglycemia Prevention  Hyperglycemia/Ketone Prevention  Considerations for Diabetic Complications

Who Is At Risk of Hypogylcemia? Premixed/Day NPH Users MDI/Pump Users Basal Insulin (Only) Users Meglitinide Users Sulfonylurea Users (esp. glyburide*) Combination Med Users

Hypoglycemia Prevention Based on Timing and Duration Activity Within 2 Activity Before or Hrs After Meal Between Meals Short Duration  Mealtime Snack Prior to Insulin/OHA Activity (<90 Minutes)  Mealtime Snack Prior to Insulin/OHA Activity Long Duration  Basal Insulin  Basal Insulin (>90 Minutes) Snack hourly Snack hourly Watch for delayed- Watch for delayed- onset hypo onset hypo

Mealtime Med Adjustments (for post-meal activity)  Low Intensity Cardio:  insulin bolus 25%  Mod. Intensity Cardio:  insulin bolus 33%  High Intensity Cardio:  insulin bolus 50%  Skip meglitinide  Skip or reduce sulfonylurea  Skip pramlintide

Snacking to prevent a low (for pre/between meal activity) Glucose Burned Per 60 Minutes of Physical Activity 50 lbs 100 lbs 150 lbs 200 lbs 250 lbs (23 kg) (45 kg) (68 kg) (91 kg) (114kg) Low Intensity 5-8g 10-16g 15-25g 20-32g 25-40g Mod. Intensity 10-13g 20-26g 30-40g 40-52g 50-65g High Intensity 15-18g 30-36g 45-55g 60-72g 75-90g

Can Exercise Cause A Rise in BG?

Adrenaline Raises BG!  Muscle Activity  Carbohydrate  Insulin  Protein (in absence of CHO)  OHA  Dehydration  Urine Diuresis  Counterregulatory Hormones

Preventing BG Rise  Adequate hydration  Avoid extreme high intensity activity  Keep “mental intensity” to a minimum  Use preemptive insulin if predictable rise

How High is Too High? No Such Number.  Performance may suffer  Hydrate  Administer Rapid-Acting Insulin (i.m.?) The Exception: Ketosis

Exercise and Ketogenesis Ins ulin  High blood sugar does G not cause ketogenesis (Body Cell) Fatty Acid  Lack of insulin or extreme insulin K+ K Energy resistance causes K + ketogenesis Kidney K + K + K + B l o o d S tr e a m   Ketones + K + dehydration causes DKA To U rine

To Prevent Ketosis/DKA with Exercise  Check blood (or urine) for ketones w/ unexplained high BG  No exercise w/positive ketones  OK to exercise if nonketotic – take 50% of usual “correction” bolus and drink plenty of water  Pump users: do not disconnect for more than 90 minutes  Avoid exercise during fever & infection

Complications & Adjustments Proliferative Retinopathy:  Limit blood pressure swings  Keep head elevated Nephropathy, ESRD:  Low-impact, Weight-bearing  Begin at very low intensity  Limit blood pressure swings

Complications & Adjustments Autonomic Neuropathy: Rating of Perceived Exertion (RPE)  HR unreliable; use RPE 1 Nothing 2 Very, Very Light 3 Very Light 4 Fairly Light  Extended warmup/cooldown 5 Somewhat Hard 6 Hard 7 Very Hard  Steady intensity; cool temps 8 Very, Very Hard Painful; Can’t Keep Up 9 Peripheral Neuropathy:  Beware of overstretching  Maintain low-impact  Non-weight-bearing?  Daily foot inspection