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 Blood Lipids  LDL, Triglycerides  HDL Hypertension  Diastolic BP 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 Resistance  Insulin Sensitivity Receptor Proliferation GLUT-4 Transport Postprandial Slower CHO Absorption Hyperglycemia  Glucose Utilization 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

• f 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

Training

Standard Care Provider Training Used Web software re:

benefits, risks, general activity suggestions

Summary pamphlet Same as advice group, + Goal setting Barriers addressed 3-month Plan Printed exercise Rx (mode,

freq., duration, intensity, progression)

Self-monitoring log

N=2069 MDs=27 N=1565 MDs=29 N=683 MDs=29

Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care 6-MONTH OUTCOMES

• Incr. in moderate /

vigorous activity (min/wk)

• Incr. In moderate /

vigorous activity (MET h/wk)

Control 31.3 2.05 Advice Only 36.4 2.41 Advice + Prescription

79.7* 5.49*

*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* Motivation

* Differences!!!

Quality Exercise vs Work/Leisure Activity

 Uses Large Muscle

Groups

 Rhythmic or

Continuous

 Over a Period of Time  At Least Somewhat

Challenging

 Tends to be “stop & go”  Intensity may be very

low or very high

 Duration varies  May not be very

challenging

 Still has benefits!

Exercise Rx “Line Item”:

Mode

• Large Muscle Groups
• Continuous or

Rhythmic

• Low-Impact (if high

risk of injury)

• Cross Train to prevent
• veruse injuries/burnout

Examples:

 Brisk Walking  Cycling  Swimming  Rowing  Stair Climbing/EFX  Aerobics Classes/Videos  Court Sports  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 9 Painful; Can’t Keep Up

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 Hrs After Meal Activity Before or Between Meals

Short Duration (<90 Minutes)

 Mealtime

Insulin/OHA Snack Prior to Activity

Long Duration (>90 Minutes)

 Mealtime

Insulin/OHA

 Basal Insulin

Snack hourly Watch for delayed-

• nset hypo

Snack Prior to Activity

Basal Insulin

Snack hourly Watch for delayed-

• nset 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 (23 kg) 100 lbs (45 kg) 150 lbs (68 kg) 200 lbs (91 kg) 250 lbs (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  Insulin  OHA  Urine Diuresis  Carbohydrate  Protein (in absence of CHO)  Dehydration

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

• High blood sugar does

not cause ketogenesis

• Lack of insulin or

extreme insulin resistance causes ketogenesis

•  Ketones +

dehydration causes DKA

K

(Body Cell)

Ins ulin G Fatty Acid Energy K K K K

B l o o d S tr e a m

Kidney To U rine K K+ + + + + +

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:

• HR unreliable; use RPE
• Extended warmup/cooldown
• Steady intensity; cool temps

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 9 Painful; Can’t Keep Up

Peripheral Neuropathy:

• Beware of overstretching
• Maintain low-impact
• Non-weight-bearing?
• Daily foot inspection

Complications & Adjustments

Peripheral Vascular Disease:

• Do not exceed “moderate” discomfort
• Gradual progression, as tolerated
• Incorporate upper-body options

Morbid Obesity:

• Start with brief activity intervals
• Build to longer duration, high frequency
• Add muscle-building activities

Adjustments for Special Populations: PREGNANCY

 Determine appropriateness:

Was patient previously active?

 Avoid bouncing, jarring motions  No lying flat on back (3rd tm)  Extra hydration; cool workout

environment (water exercise!)

 Pre-eclampsia is absolute

contraindication for exercise

Exercise Tolerance Test

(Not usually necessary for low-intensity activity)

Advisable for those with diabetes and any of these:

 Age > 50  Long diabetes duration  Additional primary risk

factors

 Presence of other

diabetic complications

Heart Disease Risk Factors

 Family History of Stroke/CAD (prior to age 65)  Hypertension  Diabetes  LDL >100, HDL <45 (f), <35 (m)  Smoking  Abdominal Obesity  Shortness of Breath w/Exertion

Exercise Rx “Line Item”:

Motivation

 Motivation through INFORMATION.  Motivation through INSPIRATION.  Motivation through IMPLEMENTATION.

Motivation through INFORMATION

Describe the

pathophysiology

Explain the

benefits

Focus on issues

pertinent to the patient

Weight loss? Appearance? Performance? Stopping/Staying off Meds? Reducing Blood Sugar?

Motivation through INSPIRATION

 Personal Follow-up

(call/letter/e-mail)

 Create a “wall of

fame” in the office

 Offer Token incentives

(water bottles, shirts, hats)

 Write/sign a contract  Network your patients

(clubs, group events)

 Issue a challenge to an

individual or group.

 Lead by example. Be

active yourself! Share your experiences.

Motivation through IMPLEMENTATION

 Provide a specific action

plan

 Choose fun modes of

activity

 Avoid injuries (variety,

warm-up, proper shoes, low impact)

 Manage the meds to

prevent hypos, facilitate weight loss

 Take on responsibility

(complete activity while doing things for

• thers or for a job)

 Accomplish 2 things at

• nce (TV, music,

phone, read, time w/friends)

IMPLEMENTATION Insights

Most Women Prefer:

 Activities with others  Supervision/Instruction  Scheduled Sessions  Low-moderate Intensity

Most Men Prefer:  Individual activities  Moderate-high intensity  Spontaneity/Flexibility

IMPLEMENTATION Insights

Most Younger People Prefer:

 Counseling from an

exercise specialist

 Evening activity  Moderate-High

Intensity Most Older People Prefer:  Morning activity  Low-Moderate Intensity

Time For YOU to Be the Exercise Specialist!

Glen Glucose

 20 y.o. college student, lives on campus  Type-1 for 12 years; no other health problems  Hemoglobin A1c 9.6, uses an insulin pump  History/English Double Major  Tired a lot. Difficulty concentrating. Grades suffering  Has access to university gym

Betty Bloodsugar

• 55 Year old female, 280 lbs (150 kg).
• Lives in inner-city; works at mall as a cashier. Also

tends to 4 grandkids.

• Type-II diabetes X 5 years; taking maximum dose of

glyburide, metformin and sitagliptin. Doctor “threatened” insulin if she does not lose weight.

• BG usually 180-200 fasting. Treated for hypertension,

background retinopathy.

• Has an old stationary bike, uses it to hang/dry clothes.
• Social butterfly.

Izzy Hyperglycemic

 72 Year old male, 5’7”, 190 lbs (100 kg).  Lives in a retirement community  Newly-diagnosed Type-II. Stable angina, autonomic neuropathy (affects balance).  On metformin now, but doctor said he might not need it if he exercises and eats less carbs.  Favorite exercise: Watching sports on TV while eating potato chips.