First 15 Minutes Exercise a day 416,175 people – average follow 8years 3 years increase in Life expectancy 15mins/day - 14% reduction all cause mortality Every extra 15 mins/day 4% extra < Mortality Chi Pang Wan et al Lancet Vol Aug 2011

Exercise in non-diabetics Decreases insulin release Stimulates glucose transport into muscle Therefore, increase in insulin sensitivity 2

Exercise in non-diabetics Increases cortisol, catecholamines Increases glucagon Free fatty acids and liver glycogen to be mobilized for energy 3

p<0.001,each Low Middle High Fitness and Incident Metabolic Syndrome; 0 Men Women LaMonte M et al. Circulation. 2005; 112: Men and 1491 Women Age-Adjusted Rate/

Fitness and Metabolic Syndrome; 11,833 Patients with 3-Day Diet Records Low intakeHigh intake Thirds of CRF Low Moderate High Finley CE et al. JADA 2006; 106:673 *Adjusted for confounders, including macronutrient intake Odds of Metabolic Syndrome*

0 LowModHigh Fitness and Incident Type 2 Diabetes; 8633 Healthy U.S. Men Diabetes incidence/1000 men Cardiorespiratory Fitness Wei M et al. Ann Int Med 1999

0 IIIIIIIV Fitness and Incident Type 2 Diabetes; 4747 Japanese Men; Tokyo Gas Company Relative risk adjusted for age and risk factors Level of Fitness Sawada SS et al. Diab Care 2003; 26:2918

LowModerateHigh Cardiorespiratory Fitness Groups Katzmarzyk et al. Arch Int Med 2004; 164:1092 All-Cause Mortality by Fitness Groups in 3,757 Men with Metabolic Syndrome Odds Ratio p for trend <0.001

Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index categories, 2316 men with type 2 diabetes at baseline, 179 deaths. Blair S N Br J Sports Med 2009;43:1-2 ©2009 by BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine

Cardiorespiratory Fitness and Cancer; Mortality in 1744 Men with Diabetes Relative risk of Cancer Death * Thompson AL et al. In progress p for trend =0.002 Low Moderate High Fitness *Adjusted for age and risk factors

Exercise and Colon Cancer Important in both primary and secondary prevention Median risk reduction: – 30-40% in men – 10-20% in women – Dose-related response; Need 30 min, 5 days per week Cancer survivors: – Improved quality of life – Less severe side effects from chemo – Appear to have reduced mortality rate

Cardiovascular Health Study; Elderly Individuals with CAD Physical Activity and Mortality 1045 women and men ≥ 65 years with coronary artery disease Followed for mortality for 9 years – 489 deaths in 7284 patient years of follow-up Physical activity assessed at baseline and at 3 years of follow-up Shows dose-response relationship PA and mortality in patients with CAD Janssen I & Jolliffe CJ. MSSE 2006; 38:418

Physical Activity and Dementia in Women and Men; ≥ 65 Years (6yr f/u) <3/week3+/week <=10 SPPB11+ SPPB Short physical performance battery scores Vs dementia incidence in 2288 women and men Wang L et al. Arch Int Med 2006; 166:1115 Age-specific incidence of dementia/1000 person-years Larsen EB et al. Ann Int Med 2006; 144:73-81 Exercise Habits Exercise and incident dementia In 1740 women and men Age- and sex-adjusted Hazard ratio for incident dementia

Computer and Physical Activity and Mild Cognitive Impairement No exercise and no computer use 1.00 Exercise but no computer use 0.68 Computer use but no exercise0.58 Both exercise and computer use0.36

RiskFactor45-64years HazardRatio(95%CI) Smoking1.56( ) Inactivity1.40( ) BMI ≥ ( ) HighBP1.35( ) HighCholesterol1.14( ) Diabetes3.25( ) Lifestyle-related Risk Factors and Risk of Future Nursing Home Admissions; 6462 Adults Valiyeva E et al. Arch Int Med 2006; 166:985

Indications for Exercise Longevity Quality of Life Socialization Weight control Disease prevention Disease management ….(I could go on)

No Physical Exercise During a 7-Day Period Men Women Slan Survey Percent

Percentage of respondents who reported no exercise in an average week Trend towards inactivity being reversed?

Percentage of respondents who reported no exercise in an average week, by age, gender and year (1998, 2002 and 2007)

‘Get Ireland Active’

Free, individual & confidential support for older adults to get more physically active

National Physical Activity Guidelines for Ireland (Adults)  At least 30 minutes of moderate intensity physical activity on 5 days a week  30 mins can be accumulated over the day but you must be active for at least 10 mins each time to make it count  Also one min of vigorous activity counts as two mins of moderate activity, i.e. 15 mins of vigorous activity equals 30 mins of moderate activity needed each day  Same for older adults  Adults with disabilities - be as active as your ability allows, aim to meet adult guidelines

National Physical Activity Guidelines for Ireland (Adults)  It should be noted that to lose weight 60 – 75 mins of moderate intensity activity a day may be required  If you have lost a significant amount of weight, to maintain weight loss, mins of moderate physical activity a day necessary to prevent weight gain.  mins (IASO 2004), mins per day (ACSM & AHA 2008)  A combination of diet and exercise appears to be the optimal strategy both for reducing weight and for maintaining weight loss.

Motivational Interviewing OARS Open Affirmations Reflective Listening Summarises

The Exercise Prescription “Think FITT” F = Frequency: – Most days of the week; 5 or more. I = Intensity: – Moderate; 50-70% of max HR or use “sing-talk” test. T = Type: – Use large muscle groups; something patients like. T = Time: – 30 minutes.

Guidelines for children and young people (aged 2-18) children should be active, at a moderate to vigorous level, for at least 60 minutes everyday children should be active, at a moderate to vigorous level, for at least 60 minutes everyday include muscle-strengthening, flexibility and bone- strengthening exercises 3 times a week. include muscle-strengthening, flexibility and bone- strengthening exercises 3 times a week. moderate to vigorous activity includes everything from sport, PE, formal exercise & active play moderate to vigorous activity includes everything from sport, PE, formal exercise & active play includes everyday activities such as walking and cycling includes everyday activities such as walking and cycling moderate activity - increased breathing & heart rate, still able to carry on a conversation, warm or sweating slightly, comfortable pace moderate activity - increased breathing & heart rate, still able to carry on a conversation, warm or sweating slightly, comfortable pace vigorous activity - breathing heavily, cannot keep a conversation going, faster heart rate & sweating a lot vigorous activity - breathing heavily, cannot keep a conversation going, faster heart rate & sweating a lot

BarrierNumber of studies References Lack of time14 10–14, 16–24 Lack of knowledge/training in PA counselling 8 10, 12, 13, 16–19, 23 Lack of success with changing patient behaviour 8 13, 14, 16–18, 21, 23, 24 PA counselling not a priority/not relevant 7 10,11,14,16,17,23,24 Lack of financial incentive/reimburseme nt for counselling 5 10,14,18,20,21 Lack of counselling protocols 5 10,12,15,20,21 Barriers to PA counselling

Lifestyle Intervention: Physical Activity Results 74% of volunteers assigned to intensive lifestyle achieved the study goal of > 150 minutes of activity per week at 24 weeks The DPP Research Group, NEJM 346: , 2002

Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) Lifestyle (n=1079, p<0.001 vs. Metformin, p<0.001 vs. Placebo) Incidence of Diabetes Risk reduction 31% by metformin 58% by lifestyle The DPP Research Group, NEJM 346: , 2002

Intervention goals  5% reduction in initial weight  Exercise ≥30 min/day  Decrease fat to <30% of caloric intake  Increase fibre to ≥15 g per 1000 kcal  Decrease saturated fat to <10% of caloric intake Tuomilehto et al. N Engl J Med 2001; 344: 1343– Study year Cumulative probability of remaining free of diabetes Intervention group Control group

13year follow up Jan Year intensive intervention 4 years 58% 7 years 43% 13years 38% 5 Years Delay in onset DM SLtDddddddddddudy year Cumulative probability of remaining free of diabetes Intervention group Control group

Mean Weight Change Placebo Metformin Lifestyle The DPP Research Group, NEJM 346: , 2002

Muscular Strengthening Exercise large muscle groups 8-12 reps; should fatigue by last rep Rest 2-3 minutes between exercises 1 set good, 2 sets better Rest day in between

Resistance training prevention diabetes men – 18 years 150 minutes/week Resistance Training alone34% reduction Aerobic Training alone 52% reduction Both 59% reduction Health Professional follow up study Arch Intern Med. 2012;172(17): doi: /archinternmed

Combined Training HbA1 DMtype2

Combined Training DM The prevalence of increases in hypoglycemic medications were 39% in the control, 32% in the resistance training, 22% in the aerobic, and 18% in the combination training groups with the Mantel-Haenszel test for linear association being significant (P =.005). The prevalence of decreases in hypoglycemic medications were 15% in the control, 22% in the resistance training, 19% in the aerobic, and 26% in the combination training groups (P =.20). The prevalence of individuals who achieved the composite outcome of either decreasing hypoglycemic medication or reducing HbA 1c by 0.5% without increasing medications were 22% in the control group, 26% in the resistance training, 29% in the aerobic, and 41% in the combination training group

Conducting exercise stress testing before walking is unnecessary. No evidence suggests that it is routinely necessary as a CVD diagnostic tool, and requiring it may create barriers to participation. ADA/ACSM November 2011

Pre-exercise evaluation Cardiac screening is controversial Decreased risk in DM of unexpected cardiac death who exercise 79% of perfusion abnormalities resolved 3 yrs with medical therapy If exercise treadmill +, poor prognosis Don’t know result of interventions 40 Clin Sports Med 2009;28: Diabetes Care 2007;30:2892-8

Pre-exercise evaluation Asymptomatic Type II with + adenosine stress compared with non screened No reduction in cardiac events High risk Type II revascularization vs aggressive medical therapy No difference in long term mortality 41 JAMA 2009;301: NEJM 2009;360:

Stress Testing Vigorous For exercise more vigorous than brisk walking or exceeding the demands of everyday living, sedentary and older diabetic individuals will likely benefit from being assessed for conditions that might be associated with risk of CVD, contraindicate certain activities, or predispose to injuries, including severe peripheral neuropathy, severe autonomic neuropathy, and preproliferative or proliferative retinopathy

Who to do stress test? Low to moderate intensity, good control, not many risk factors Start program Out of shape, starting program Start low to moderate intensity OR non-exercise imaging 43 Handbook of Exercise in Diabetes 2002 Clin Sports Med 2009;28:379-92

Who to do stress test? If moderate to high intensity exercise AND/OR ADA guideline risk factors Autonomic neuropathy PVD, retinopathy + EKG Stress test OR modify risk factors prior to exercise 44 Handbook of Exercise in Diabetes 2002 Clin Sports Med 2009;28:379-92

FACTORS WHICH PREVENT EXERCISE READYNESS TO CHANGE Health concerns Family commitments Work commitments Transport difficulties Weather Cost Security concerns

Exercise Type II Exercise reverses deficits in metabolism Basal insulin HbA1c Basal glucose Liver glucose production Insulin stimulated glucose uptake GLUT4 receptors Insulin sensitivity Cholesterol, triglycerides 46 GSSI # ;16(3)

Exercise Benefits 20-30% reduction in HbA1c in Type II Decrease lipids Decrease blood pressure Weight loss and maintenance Reduce metabolic syndrome Reduce risk of CAD !! 47

Physical Activity and Mortality DM Total PA was associated with lower risk of CVD and total mortality. Compared with physically inactive persons, the lowest mortality risk was observed in moderately active persons: Hazard ratios were 0.62 (95% CI, ) for total mortality and 0.51 (95% CI, ) for CVD mortality. Leisure-time PA was associated with lower total mortality risk, and walking was associated with lower CVD mortality risk. In the meta-analysis, the pooled random-effects hazard ratio from 5 studies for high vs low total PA and all-cause mortality was 0.60 (95% CI, ). Annals of Internal Medicine Online first August 2012

Borg perceived exertion scale 6 No exertion at all 7 Extremely light 8 9 Very light - (easy walking slowly at a comfortable pace) Light Somewhat hard (It is quite an effort; you feel tired but can continue) Hard (heavy) Very hard (very strenuous, and you are very fatigued) Extremely hard (You can not continue for long at this pace) 20 Maximal exertion

Borg perceived exertion scale Perceived Exertion Scale Level 1: I'm watching TV and eating bon bons Level 2: I'm comfortable and could maintain this pace all day long Level 3: I'm still comfortable, but am breathing a bit harder Level 4: I'm sweating a little, but feel good and can carry on a conversation effortlessly Level 5: I'm just above comfortable, am sweating more and can still talk easily Level 6: I can still talk, but am slightly breathless Level 7: I can still talk, but I don't really want to. I'm sweating like a pig Level 8: I can grunt in response to your questions and can only keep this pace for a short time period Level 9: I am probably going to die Level 10: I am dead

METs3.5-4  Moderate  Walking at a brisk pace (1 mi every 20 min)  Weight lifting, water aerobics  Golf, not carrying clubs  Leisurely canoeing or kayaking  Walking at a very brisk pace (1 mi every 17 to 18 min)  Climbing stairs  Dancing (moderately fast)  Bicycling <10 mph, leisurely

METs4.5-6 Moderately Vigorous Plus Slow swimming Golf, carrying clubs Walking at a very brisk pace (one mi every 15 min) Most doubles tennis Dancing (more rapid) Some exercise apparatuses Slow jogging (one mi every 13 to 14 min)

Vigorous Exercise  Hiking  Rowing, canoeing, kayaking vigorously  Dancing (vigorous)  Some exercise apparatuses  Bicycling 10 to 16 mph  Swimming laps moderately fast to fast  Aerobic calisthenics  Singles tennis, squash, racquetball  Jogging (1 mile every 12 min)  Skiing downhill or cross country

Why Resistance Training? Improves metabolism – proven reduction in Insulin Resistance, incidence of D.M., additive effect to aerobic exercise in prevention and treatment of IHD Improves muscle strength – less falls/#s Reduced Osteoporosis 1year increase BMD 1.3% Controls loss 1.2% Arthritis – Reduced pain Improved function

Exercise that uses muscular strength to move a weight or move against a resistive load In diabetes resistance exercise of the major muscle groups on 2 non consecutive days in the week is recommended

Resistance Training Resistance can be own body weight Press Up / Sit Up Light Weights – Dumb Bells Resistance bands

Progression Over time and as the person achieves 3 sets of reps the weight can be increased, as this produces impoved blood glucose effects As the weight increases the number of reps per set can be reduced to 8-10

7 Investments that work for physical activity 1. Whole-of-school’ programs 2. Transport policies and systems that prioritise walking, cycling and public transport 3. Urban design regulations and infrastructure that provides for equitable and safe access for recreational physical activity, and recreational and transport-related walking and cycling across the life course 4. Physical activity and NCD prevention integrated into primary health care systems 5. Public education, including mass media to raise awareness and change social norms on physical activity 6. Community-wide programs involving multiple settings and sectors & that mobilize and integrate community engagement and resources 7. Sports systems and programs that promote ‘sport for all’ and encourage participation across the life span