Barbara Schlichte Father diagnosed with Type 2 Father-in-law died from complications with type 2 Genetics Dad Definition of Diabetes Mellitis Epidemiology Clinical Aspects Treatment Effects of Exercise Exercise Testing Exercise Prescription Summary Conclusion Diabetes mellitus is a group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both. Abnormalities in metabolism of CHO, protein and fat are present. People with diabetes have bodies that don’t produce or respond to insulin. Without effective insulin, hyperglycemia (elevated blood glucose) occurs. Type 1 Type 2 Gestational Other types Absolute deficiency of insulin Marked reduction of beta-cells in pancreas Thought to involve an autoimmune response-no known means to prevention Exogenous insulin must be supplied Prone to ketoacidosis Accounts for 5% to 10% of diagnosed cases Can occur at any age although most affected people are children and young adults Relative insulin deficiency-insulin resistant ◦ Elevated, reduced or normal insulin levels Risk factors include: (test on diabetes website) ◦ ◦ ◦ ◦ ◦ ◦ ◦ Genetics Older age Obesity (particularly abdominal) Sedentary lifestyle Gestational diabetes Pre-diabetes Race or ethnicity Most cases do not require exogenous insulin Do not develop ketoacidosis except in cases of unusual stress Accounts for 90% to 95% of diabetes cases Usually occurs after the age of 40 but is developing in young adults and youth NO CURE-only management! Glucose intolerance during pregnancy Due to contrainsulin effects of pregnancy 20% to 50% of women with gestational diabetes develop type 2 within 5 – 10 years Gestational Results from specific genetic syndromes, surgery, drugs, malnutrition, infections, or other illnesses Depending on pathophysiology, may or may not require insulin Other types Total: 25.8 million children and adults in the US-8.3% of the population have diabetes Diagnosed: 18.8 million Undiagnosed: 7 million Pre-diabetes: 79 million New Cases: 1.9 million new cases were diagnosed in 2010 Cost: $174 billion! In 2007 Medical costs are 2.3 times more for diabetics 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Percentage of Ethnic Group with type 2 diabetes 7.1% 8.4% 12.6% 11.8% Non-Hispanic Asian Non-Hispanic Hispanics whites Americans blacks Frequent urination Extreme thirst Extreme hunger Unusual weight loss Extreme fatigue and irritability Type 1 Any of the type 1 symptoms Frequent infections Blurred vision Cuts/bruises that are slow to heal Tingling/numbness in hands/feet Recurring skin, gum or bladder infections OR NO symptoms! Type 2 Diagnosis Criteria Diabetes FPG≥126 mg/dl CPG≥200 mg/dl 2hPG≥200 mg/dl Pre-diabetes Impaired fasting glucose Impaired glucose tolerance Normal FPG100-125 mg/dl 2hPG140-199 mg/dl FPG<100 mg/dl 2hPG<140 mg/dl *2bPG, 2-hour plasma glucose level *FPG, fasting plasma glucose * CPG Casual plasma glucose Adults with diabetes have heart disease death rates 2 to 4 times higher than those without diabetes Adults with diabetes have a 2 to 4 times greater risk of having a stroke In 2005-2008, 67% of adults with diabetes had high blood pressure Diabetes is the leading cause of new cases of blindness in adults ages 20 to 74 Leading cause of kidney failure in US ◦ Accounts for 44% of cases in 2008 Neuropathy-about 60% to 70% of diabetics have some form of nerve damage Amputation-about 60% of nontraumatic lower limb amputations occur in diabetics Insulin therapy ◦ Type 1 ◦ Some type 2 Individual nutritional care plan Exercise-especially for type 2 Oral medication/type 2 Generic name Rapid acting Insulin lispro Insulin aspart Insulin glulisine Short acting Regular Intermediate acting NPH Lente Long acting Insulin glargine Ultralente Trade Name Humalog NovoLog Apidra Humulin R Novolin R Onset <15 min Peak 30-90 min Duration 1-3 h 3-6 h 30-60 min 2-3 h 2-4 h 4-10 h 10-16 h 2-4 h Does not peak 18-36 h Humulin N Novolin N Humulin L Lantus Humulin U Generic name Trade name Biguanides Metformin Metformin(liquid) Glucophage, Glucophage XR, Riomet Glucosidase inhibitors Acarbose Miglitol Meglitinides Nateglinide repaglinide Precose Glyset Starlix Prandin Concerns with exercise May produce hypoglycemia with postprandial exercise May produce hypoglycemia with postprandial exercise Generic name Secretagogues Acetohexamide Chlorpromide Tolazimide Tolbutamide Glimepride Glipizide Glyburide Thiazoladinediones Pioglitazone Rosiglitazone Dipeptidyl peptidase4 inhibitors Sitagliptin Trade name Generic only Diabinese Tolinase Orinase Amaryl Glucotrol, Glucotrol XL Diabeta, Glynase, PresTab, Micronase Actos Avandia Januvia Concerns with exercise Can produce hypoglycemia during or after exercise No hypoglycemia unless given with another drug Generic name Trade name Comments and concerns with exercise Exantide Byetta Exantide is used in treatment of type 2 and is found to increase postprandial insulin response, delay gastric emptying, suppress glucagon secretion, and reduce appetite Pramlintide Symlin Pramlintide is a synthetic hormone similar to human amylin. It may be used in combination with insulin therapy for treatment of either type 1 or 2. Pramlintide works by suppressing glucagon secretion and delaying gastric emptying. Insulin and counter regulatory hormones don’t respond to exercise in the normal manner Balance between peripheral glucose utilization and hepatic glucose production may be disturbed= hypo/hyperglycemia Insulin allows glucose to enter the cells of insulin-sensitive tissue Oral and injectable agents for type 2 diabetes are meds that help the pancreas secrete more insulin, alter CHO absorption, reduce liver glycogenolysis, increase insulin sensitivity, or a combination of effects Meds may cause hypoglycemia ◦ Pay attention to med timing, food intake, blood glucose level before and after exercise Muscle contractions increase glucose uptake Both aerobic and resistance exercises increase GLUT4 abundance and BG uptake Insulin action and glucose tolerance is increased (type 2) Dependent on several factors ◦ ◦ ◦ ◦ ◦ ◦ ◦ Use and type of meds to lower blood glucose Timing of meds Blood glucose level prior to exercise Timing, amount, and type of previous food intake Presence and severity of diabetic complications Use of other meds Intensity, duration and type of exercise Weight loss (type 2) Improved insulin sensitivity Possible prevention of type 2 For those with type 2-possible improvement in blood glucose control Improved CV health ◦ Lower triglycerides ◦ Lowers blood pressure Exercise testing using protocols for populations at risk for CAD recommended in individuals who: Have type 1 and are over 30 yrs Have had type 1 longer than 15 years Have type 2 and are over 35 yrs Have either type 1 or 2 and one or more other CAD risk factors ◦ Have suspected or known CAD, or ◦ Have any microvascular or neurological diabetic complications ◦ ◦ ◦ ◦ Methods Measures endpoints Aerobic Cycle (ramp protocol 17 W/min; staged protocol 25-50 W/3 min stage) Treadmill (1-2 METs/stage) 12-lead ECG, HR Serious dysrhythmias >2 mm ST-segment depression or elevation Ischemic threshold Significant T-wave change BP RPE (6-20) SBP >250 mmHg or DBP >115 mmHg Onset of peripheral pain People with diabetes who don’t meet any of the criteria for CAD may be tested with use of protocols for the general healthy population Primary objectives are to: ◦ Identify the presence and extent of CAD ◦ Determine appropriate intensity range for aerobic exercise training Must be individualized according to med schedule, presence and severity of diabetic complications, and goals of program Hypoglycemic meds=additional 15 g of CHO before or after exercise 15 to 30 g CHO (fat free) every hour during vigorous or exercise>60 min Proper hydration Good foot care-proper shoes and socks Athletes will most often know their limits but trial and error with beginners-monitor BG!! Active retinal hemorrhage or recent retinopathy therapy Illness or infection Blood glucose >250 mg/dl and ketones are present Blood glucose <70 mg/dl If blood glucose is <100 mg/dl, CHO should be consumed Modes Goals Intensity/frequenc y/duration Time to goal Aerobic Large muscle activities Increase aerobic capacity, time to exhaustion, work capacity, BP response to exercise, Reduce CV risk factors 50-80% peak HR 50-80% VO2peak Monitor RPE 4-7 sessions/week 20-60 min/session 4-6 month Strength Free weights Weight machines Elastic tubing or bands Increase max reps Improve performance for competitive patients low resistance, high reps for most High resistance OK for patients with well controlled diabetes 4-6 months Modes Anaerobic High-intensity intervals Goals Time to goal Only for athletes Same as for in good diabetic nondiabetic control athletes Flexibility Stretching/yoga Maintain/ increase ROM Improve gait Neuromuscular Yoga Improve balance and coordination Functional Activity-specific exercise Intensity/freque ncy/duration Increase ADLs Increase vocational potential Increase self confidence Limited data; 23 x’s/week may suffice Individualized to each client 4-6 months Diabetes song http://www.youtube.com/watch?v=Ni8lwD7Z 0c8 Diabetes is a disease that should be taken seriously Some type 2 can be managed with diet and exercise If there are no significant complications with diabetes mellitus, patients can enjoy exercise with very few limitations Exercise for type 2 patients is a must!! 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