Exercise therapy in type 2 diabetes: state of the art Dominique Hansen, PhD, FESC
State-of-the-art exercise in T2DM Effectiveness of exercise intervention Prevention Treatment Novel/new exercise modalities Experimental manupulations Future of exercise therapy Where do we go from here?
Prevention of T2DM
Prevention of T2DM
Treatment of T2DM Qiu S, et al. PLoS One. 2014 Oct 17;9(10):e109767
Treatment of T2DM Umpierre D, et al. JAMA 2011; 305: 1790-99
Treatment of T2DM
Treatment of T2DM Umpierre D, et al. Diabetologia 2013; 56: 242-51
Optimizing exercises
Optimizing exercises
New/other exercise types
New/other exercise types
New/other exercise types
New/other exercise types
New/other exercise types Changes in peripheral insulin sensitivity after three months of endurance type exercise training with exercise sessions performed in either a fasted (solid lines) or postprandial state (dotted lines).
New/other exercise types Fasted Postprandial Time effect Group *time effect Pretest Posttest P value Fasting blood glucose (mmol/l) 11.4 ± 4.4 9.8 ± 5.0 9.0 ± 2.9 7.8 ± 2.0 <0.05 NS HbA1c (%) 7.9 ± 1.8 7.7 ± 1.7 6.9 ± 0.9 6.7 ± 0.9 HbA1c (mmol/l) 63 ± 7 61 ± 7 52 ± 4 50 ± 4 M (mg/kg/min) 11.6 ± 12.9 20.6 ± 17.9 14.5 ± 15.7 25.1 ± 18.6 <0.01
New/other exercise types
New/other exercise types
New/other exercise types
New/other exercise types
New/other exercise types
New/other exercise types
Difficulties ahead Type 2 diabetes
Difficulties ahead AMI with PCI or CABG Hypercholesterolemia Heart failure Hypertension Sarcopenia Cardiomyopathy Type 2 diabetes Obesity Pacemaker/ICD Claudicating intermittens
And what to do with prescription of certain medications? Difficulties ahead And what to do with prescription of certain medications? Beta-blockers Statins Sulfonylurea/meglitinide Exogenous insulin administration … And what to do with certain adverse events during exercise testing? Myocardial ischemia Exercise-induced cardiac arrhythmias
And what to do with prescription of certain medications? Difficulties ahead And what to do with prescription of certain medications? Beta-blockers Statins Sulfonylurea/meglitinide Exogenous insulin administration … And what about safety precautions during exercise for all these indications? Nobody really knows….
Comparing different clinicians
Comparing different clinicians Case 1 Case 2 Case 3 Case 4 Case 5 Age: 65 years Body height: 171 cm Body weight: 65 kg Sex: male VO2max: 2500 ml/min (116% of predicted normal value) Resting HR: 55 bts/min Peak exercise HR: 123 bts/min Total cholesterol: 180 mg/dl Fasting glycaemia: 92 mg/dl Blood pressure: 145/82 mmHg Medication intake: beta-blocker, nitrate, statin, antiplatelet. Referred to rehabilitation for: acute myocardial infarction with PCI. Co-morbidities: None. Age: 55 years Body height: 160 cm Body weight: 85 kg Sex: female VO2max: 1600 ml/min (108% of predicted normal value) Resting HR: 102 bts/min Peak exercise HR: 151 bts/min Total cholesterol: 267 mg/dl Fasting glycaemia: 108 mg/dl Blood pressure: 115/72 mmHg Medication intake: statin, ACE-inhibitor, orlistat, antiplatelet, metformin, sulfonylurea. Referred to rehabilitation for: obesity. Co-morbidities: type 2 diabetes. Additional information: gonarthrosis present. Age: 70 years Body height: 182 cm Body weight: 80 kg VO2max: 1500 ml/min (73% of predicted normal value) Resting HR: 52 bts/min Peak exercise HR: 112 bts/min Total cholesterol: 189 mg/dl Fasting glycaemia: 102 mg/dl Blood pressure: 125/80 mmHg Medication intake: statin, antiplatelet, beta-blocker, digitalis, mucolytics, bronchodilators. Referred to rehabilitation for: AMI with CABG. Co-morbidities: Heart failure with preserved ejection fraction, mild COPD. Body height: 165 cm Body weight: 90 kg VO2max: 1450 ml/min (90% of predicted normal value) Resting HR: 52 bts/min Peak exercise HR: 100 bts/min Total cholesterol: 234 mg/dl Fasting glycaemia: 115 mg/dl Blood pressure: 135/75 mmHg Medication intake: beta-blocker, statin, exogenous insulin, nitrate, erythropoietin. Referred to rehabilitation for: stable myocardial ischemia (threshold at 87 bts/min) Co-morbidities: renal failure, type 1 diabetes. Additional information: chronic aspecific low back pain present. Age: 79 years Body height: 170 cm Body weight: 59 kg VO2max: 1250 ml/min (88% of predicted normal value) Resting HR: 56 bts/min Peak exercise HR: 111 bts/min Total cholesterol: 178 mg/dl Fasting glycaemia: 125 mg/dl Blood pressure: 135/87 mmHg Medication intake: beta-blocker, bronchodilator, antiplatelet. Referred to rehabilitation for: peripheral vascular disease. Co-morbidities: cachexia and frailty, COPD.
Comparing different clinicians
Comparing different clinicians
Comparing different clinicians
Need for standardization
EXPERT tool
EXPERT tool
EXPERT tool
EXPERT tool
EXPERT tool
EXPERT Tool Digital, interactive decision support tool for exercise prescription Endorsed by the European Association of Preventive Cardiology www.escardio.org/Education/Practice-Tools/CVD-prevention-toolbox/EXPERT-Tool
Time for telemedicine?
Drug-exercise interaction? + = Enhanced effects of exercise? + = Enhanced effects of drugs?
One last thing to (re)consider… But how, by what mechanism? By HbA1c reduction only?
Or maybe two things to (re)consider? This is often what we aim for…. But this is what we should aim for….
Dominique.hansen@uhasselt.be