1. Pulse para añadir texto T2DM EXERCISE PROGRAMMES (Specific Needs) Agustín Meléndez-Ortega Ph.D.

2. INTRODUCTION  Definition and prevalence  T1DM - T2DM  Aims of the exercise programme  Organizational preconditions  Demands for qualification of instructors  Evaluation measures  Learning outcomes

3. Pulse para añadir texto DEFINITION and PREVALENCE

4. Diabetes Mellitus Chronic illness (hyperglycemia)  Hyperglycemia: results from defects in insulin secretion, receptors, or both  Associated to obesity, hypertension, high cholesterol & cv mortality  Inactivity (sedentarism) illness Image: Medline Plus

5. Glucose Transporter -Type 4 (GLUT4) Goodyear y Horton 2001 - Rate limiting step in glucose utilization - Facilitated Diffusion - GLUT4 major transporter isoform - Exercise and insulin are powerful stimulators GlycogenGlycolysis

6. Glucose transport in the presence of insulin

7. GLUT4 translocation in the skeletal muscle Goodyear y Horton 2001

8. Exercise and insulin action on the skeletal muscle Goodyear y Horton 2001

9. Prevalence Source: International Diabetes Federation; MedMarket Diligence, LLC, report #D500, "Diabetes Management, Worldwide, 2005-2015: Products, Technologies and Markets in the U.S., Europe, Japan & Rest of World."

10. European Prevalence of Diabetes There are about 50-60 million people with diabetes in the European region, or about 10.3% of men and 9.6% of women aged 25 years and over. There are about 50-60 million people with diabetes in the European region, or about 10.3% of men and 9.6% of women aged 25 years and over. Prevalence of diabetes is increasing among all ages in the European region (overweight and obesity, unhealthy diet and physical inactivity). Prevalence of diabetes is increasing among all ages in the European region (overweight and obesity, unhealthy diet and physical inactivity). Source: OECD (2012), “Diabetes prevalence and incidence”, in Health at a Glance: Europe 2012, OECD Publishing. http://dx.doi.org/10.1787/9789264183896-17-en

11. Pulse para añadir texto AIMS of the EXERCISE PROGRAMME

12. Exercise Programme (DM1) Positive effects of training on insuline resistance Strong evidence Modetare evidence Limited evidence No evidence ACBD Pathogenesis Physical fitness or strength Symptoms specific to the diagnosis Quality of life Source: Pedersen BK and Saltin B; Scand J Med Sci Sports; 2006:16 (Suppl:1)

13. Exercise Programme (DM2) Positive effects of training on insulin resistance Strong evidence Moderate evidence Limited evidence No evidence ACBD Pathogenesis Physical fitness or strength Symptoms specific to the diagnosis Quality of life Source: Pedersen BK and Saltin B; Scand J Med Sci Sports; 2006:16 (Suppl:1)

14. Aims of the Exercise Programme General for Health General for Health  Physical Fitness  Risk Factors Specific Specific  Body Composition  Short term Control  Medium term control *Adj. for age and examination year Church TS et al. Arch Int Med 2005; 165:2114 CVD Mortality Risk* by Fitness and BMI Categories, 2316 Men Diabetes, 179 CVD Deaths

15. ORGANIZATIONAL PRECONDITIONS Scenarios (Time with the disease)  T2DM < 2 years  T2DM 2-5 years  T2DM > 5 years  Elderly (> 65) T2DM CV Fitness  < pred. VO2 max  > pred. VO2 max Body composition  > BMI 30  < BMI 30 Source: Modified from Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007.

16. ORGANIZATIONAL PRECONDITIONS Medical check (CV) Type of diabetes  Metabolic syndrome  Body composition (% body fat) Medication Medication  Sulfonyl ureas, etc...  Insulin Scenarios  Obese people  Insulin  Elderly

17. Scenario 1 : Obese patients recently diagnosed  Intense to moderate aerobic exercise (Daily exercise preferable).  Combined with a caloric restriction to produce a weekly weight loss of ½ to 1 kilo.  At least 1 weekly session of strength training to avoid loss of muscle mass. Source: Modified from de Praet, SF y Van Loon, LJ. J. Appl Phys 103: 1113-1120, 2007. Image: Exercise Physiology: Wilmore y Costill Image: Exercise Physiology: Wilmore y Costill

18. Scenario 2 : Patients who have had the condition for some time and have been treated with insulin Bear in mind comorbidities. Bear in mind comorbidities. Programme intermittent exercises, relatively intense strength training exercises and aerobic-type exercises Programme intermittent exercises, relatively intense strength training exercises and aerobic-type exercises Once an improvement in muscle strength and functional performance has been achieved, progress to a more generic intervention programme (with more intense aerobic exercise) Once an improvement in muscle strength and functional performance has been achieved, progress to a more generic intervention programme (with more intense aerobic exercise) Fuente: Praet, SF y Van Loon, LJ; J. Appl Phys 103: 1113-1120, 2007. Image: Robert Newton. Edith Cowan University Image: Robert Newton. Edith Cowan University

19. Scenario 3 : Elderly people recently diagnosed with T2DM  Important: Strength training (To avoid or reverse the loss of muscle mass).  Co-intervention with diet Source: Praet, SF y Van Loon, LJ.; J. Appl Phys 103: 1113-1120, 2007. Image: Robert Newton. Edith Cowan University

20. Scenario 4 : Insulin resistant state with no complications  Glycemic control, cardiorespiratory fitness and microvascular function can be improved with a more vigorous programme [including strength training and flexibility] Source: Praet, SF y Van Loon, LJ. J.; Appl Phys 103: 1113-1120, 2007. Images: Left. Dr. Robert Newton. Edith Cowan University; Right. Human Kinetics Catalog

21. Pulse para añadir texto DEMANDS for QUALIFICATION of the INSTRUCTORS

22. Demands for Qualification of the Instructors General Exercise Programmes (See Capacity Building-Active Age) General Exercise Programmes (See Capacity Building-Active Age) Diabetic specific and risk factors Diabetic specific and risk factors Management of hyper and hypoglycemia Management of hyper and hypoglycemia Avoidance of complication for comorbidities Avoidance of complication for comorbidities Adaptation for contraindications Adaptation for contraindications

23. Demands for Qualification of the Instructors Programming Programming Complications (Comorbidities) Complications (Comorbidities)

24. Bear in mind that subjects are usually sedentary, with high blood pressure and cholesterol and overweight or obese, possible contraindications. Comorbidities Bear in mind that subjects are usually sedentary, with high blood pressure and cholesterol and overweight or obese, possible contraindications. Comorbidities  Physical Fitness  Body composition  Treatment  Orthopedic limitations (e.g. feet…), Programming

25. RetinopathyHypertension Autonomous neuropathy Peripheral Neuropathy Nephropathy Source: B. N. Campaigne: Exercise and Diabetes Control. ACSM´s Resource Manual, 1998 Complications of Diabetes (Comorbidities)

26. Complications

27. Source: B. N. Campaigne: Exercise and Diabetes Control. ACSM´s Resource Manual, 1998 Complications of Diabetes (Comorbidities) Proliferative retinopathy Microangiopathy Severe neuropathy Nephropathy Evidence of underlying CV disease Bear in mind the absolute contraindications for exercise Lack of glycemic control (T1, >250 mg/dL y KK) (T2 >300 mg/dL)

28. Evaluation Measures Pre and post stress test - (CV risk) & Classification Pre and post stress test - (CV risk) & Classification Subject evaluation Subject evaluation  Glucose response to exercise (programme)  Fitness evaluation (Blair)  Diabetes evolution (A1C)  Controls and glucose response to exercise Programme evaluation Programme evaluation  Attendance  Satisfaction  Results

29. Learning Outcomes FOR THE SUBJECT FOR THE SUBJECT How to improve blood glucose control with exercise How to improve blood glucose control with exercise Decrement achieved in risk factors Decrement achieved in risk factors Short term response Short term response Medium term response Medium term response How to act if complications arise How to act if complications arise Possible mechanism for different types of exercise Possible mechanism for different types of exercise