The-role-of-physical-activiy-in-managing-diabetes_AL

Which type of exercise is best for lowering HbA1c in Type 2 DM?Combined training seems to be best Only combined training lowered HbA1c in those with HbA1c less than 7.5%... 2004 In type

The role of Physical activity in managing

diabetes

Dr Alistair Lumb, Oxford on behalf of

Professor Rob Andrews University of Exeter / Taunton NHS trust

23rd May 2019

• Supervised exercise studies

• Real world studies

• Breaking up sitting

Supervised exercise programs

Umpierre, D et al JAMA 2011;305:1790-1799

Which type of exercise is best for lowering HbA1c in Type 2 DM?

Combined training seems to be best

Only combined training lowered HbA1c in

those with HbA1c less than 7.5%

Physical activity and fitness in T2DM

Physical activity and mortality in T2DM

Physical activity and microvascular

complications in T2DM

• No definitive study

• Some studies suggest protective

against eyes and kidney complications

• Others do not

Exercise and mental health and T2DM

Measure Type of

exercise

Number of studies

Results

Quality of life

Aerobic Five 4 no effect, 1 improvementAnaerobic Four 3 no effect, 1 improvementMixed Ten 7 no effect, 3 improvement

Well-being

Aerobic Three 2 showed improvement, 1 did

notAnaerobic Two 1 showed improvement other

did notMixed One No effect

Supervised exercise and Beta cell function

Dela F et al Am J Physiol Endocrinol Metab 2004

In type 2 DM regular exercise improves beta cell function

Physical

activity

Beneficial

Uncertain / Limited data

Summary 1

The more exercise the better Combined exercise seems to yield the best results

Physical activity and Type 1 DM

Joslin Victory Medal for living with T1D

In adults with T1DM no clear evidence

exercise improves HbA1c

Does though seem to be some

effect in children But need for better studies

Kennedy A,et al (2013) Does Exercise Improve Glycaemic Control in Type 1 Diabetes? A Systematic Review and Meta-Analysis PLoS ONE 8(3): e58861 doi:10.1371/journal.pone

HbA1c, exercise and T1DM

Which type of exercise is best for

lowering HbA1c in T1DM?

• Not known

• No large study that has compared

one form of exercise with another.

• But HIT might is emerging as one of safest

The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 2, February 2019, Pages 604–612, https://doi.org/10.1210/jc.2018-01309

Figure 1 Effect of 6 wk of High intensity training (HIT) and Moderate intensity

continuous training (MICT) on Vo2peak (A) Mean and (B) individual responses in patients with T1DM

Figure 2 Change in BG concentration after exercise in the fed state

with HIT and MICT (A) Mean and (B) individual responses in patients with T1DM

The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 2,

February 2019, Pages 604–612, https://doi.org/10.1210/jc.2018-01309

Physical activity and fitness in T1DM

0 10 20 30 40 50 60

VO2 max before V02 max after

Controls T1DM

Physical activity and mortality in T1DM

The Pittsburgh IDDM Morbidity and Mortality study,

a large retrospective study found

• Men who had had T1DM for 25 years, who had

participated in team sports during high school

were three times less die than those that did not

• This pattern was not seen in women

• The level of physical activity in adulthood also

predicted mortality at 6 years

LaPorte RE et al Pediatrics 1986

Physical activity and complication in T1DM

Exercise and mental health and T1DM

1 1.2

1.4

1.6

1.8

2 2.2

Exercise and Beta cell function and T1DM

The time has come to test the beta cell preserving effects of exercise in patients with new onset type 1 diabetes Narendran P, Solomon TP, Kennedy A, Chimen M, Andrews RC; Diabetologia, November 2014

Animals studies show effect

To date no Human studies

FitnessInsulin requirement

LipidsEndothelial function

MortalityInsulin resistance

CVD Wellbeing (children))

Beneficial

Physical

activity

Type 1 diabetes

Microvascular complications

OsteoporosisCancer

Beta cell function

Blood pressure

Glycaemic control

Uncertain

or limited data Summary 2 exercise and type 1 DM

What about real world studies?

“ Running a red light does not count You still need to get more exercise.”

Look ahead study

5,145 randomised (56.9% of those screened)

2,570 Intensive lifestyle intervention

Weekly behavioral group

Calorie controlled diet

with meal replacement

Home based exercise programme

Orlistat after 6/12 if needed

2463

DM support & education

3 group sessions in year

Look ahead Diabetes Care 2007 Jun;30(6):1374-83

Look AHEAD study

Intervention +116 min

(+ 871 Kcal)/ wk (+ 348 Kcal)/ wk + 46 min Control +14 min

(+107 Kcal)/ wk (+ 104 Kcal)/wk + 14 min

No association with increase in exercise and lowering of HbA1c

Look ahead Diabetes Care 2007 Jun;30(6):1374-83

Summary 3

• Benefit in Hb1c shown

• But even with frequent contact

unable to not achieve 150 minutes of exercise in the majority of patients

with type 2 diabetes.

American simple advice study

Di Loreto C (2003) Diabetes Care:26:2:404-408

340

182 Exercise

30 Minute consultation

30 minute exercise advice

1 month exercise advice

Every 3 months exercise advice

Standard Exercise advice

Normal weight - iso caloric diet

Overweight – negative caloric diet

158

Control

30 Minute consultation Every 3 months saw Doctor Standard Exercise advice Normal weight - iso caloric diet Overweight – negative caloric diet

American simple advice study

Before

Exercise Before

Control After

Exercise After

BMI 29 + 0.3 29.3 + 0.2 30.4 + 0.3 28.9 + 0.2*

Di Loreto C (2003) Diabetes Care:26:2:404-408

Average was 3 times target 69% reached guidelines

0.5% lowering compared

To control

Physical activity advice

Umpierre, D et al JAMA 2011;305:1790-1799

Copyright restrictions may apply.

-0.58

-0.16

Summary 4

• Uptake of exercise is variable in

studies of people with T2DM

• Activity advice needs to be given with dietary advice to lower HbA1c

Can standing more often help?

B.Duvivier et al, Diabetologia March 2017

Fitness Insulin requirement

Lipids Endothelial function Mortality Blood pressure Beta cell function Glycaemic control

Fitness Insulin requirement

Lipids Endothelial function Mortality Insulin resistance

CVD Wellbeing (only children )

Microvascular complications Osteoporosis Cancer CVD Wellbeing

Type 2 diabetes

Type 1 diabetes

Beneficial

Uncertain / Limited data

What are the recommendations?

150 minutes per week of

moderate to vigorous aerobic activity Resistance training

three times a week

+

Reduce sitting time – try to get up three times per hour