1. Exercise training in diabetes Prof. dr. Dominique Hansen

2. Obesity epidemic

3. Prevalence of obesity and severe obesity 2008–30 in USA

4. Obesity epidemic

5. Diabetes epidemic

8. European Opinion Research Group: Eurobarometer Report 2014

9. Exercise: why? EXERCISE TRAINING = INVESTMENT IN MORE AND BETTER TIME

10. Exercise: why?

13. Prevention of type 2 diabetes – 3234 glucose-intolerant subjects Knowler et al. N Engl J Med 2002; 346: 393 Exercise in type 2 diabetes: why? Daily metformin intake = -33% T2DM incidence Change in lifestyle = -58% T2DM incidence

14. Prevention of type 2 diabetes Through exercise training only? 37-49% risk reduction Laaksonen DE, et al. Diabetes 2005; 54: 158-65 Exercise in type 2 diabetes: why?

15. In 1982 it was found how blood glucose content could decrease as result of exercise – Elevation of skeletal muscle insulin sensitivity – Richter EA, et al. J Clin Invest 1982; 69: 785-93 – Richter EA, et al. Am J Physiol 1984; 246: E476-82 – Elevation of skeletal muscle glucose uptake…but also by a non- insulin dependent pathway – Garetto LP, et al. Am J Physiol 1984; 246: E471-5 – Glucose utilisation could increase 20-fold as result of exercise Exercise in type 2 diabetes: why?

16. Praet et al. Clin Sci 2006; 111: 119 13.30h hyperglycemic 0.4h hyperglycemic Exercise in type 2 diabetes: why?

17. Praet et al. Med Sci Sports Exerc 2006; 38: 2037 Exercise in type 2 diabetes: why?

18. Qiu S, et al. PLoS One. 2014 Oct 17;9(10):e109767

19. Exercise in type 2 diabetes: why? Umpierre D, et al. JAMA 2011; 305: 1790-99

20. Exercise in type 2 diabetes: why? Umpierre D, et al. Diabetologia 2013; 56: 242-51

21. Long-term exercise training in type 2 diabetes patients also positively affects: – Quality of life – Physical fitness – Inflammatory markers – Cardiovascular disease risk factors Blood pressure, waist circumference, lipid profile Exercise in type 2 diabetes: why?

22. Fear of exercise No exercise Lowering in endurance capacity Increase in fat mass Worsening in CVD risk factors Worse glycemic control Further decrease in motivation to exercise Further worsening in fat mass, exercise tolerance, CVD risk factors and glycemic control Exercise in type 1 diabetes: why?

24. Exercise physiology in obesity Can be significantly different!

25. = Exercise physiology in obesity Tanner CJ, et al. Am J Physiol 2002; 282: E1191  Muscle fibre type composition

26. Exercise physiology in obesity  Body composition Biolo G, et al. Clin Nutr 2014; 33; 737

27. Exercise physiology in obesity  Hormonal disturbances Mittendorfer et al. Am J Physiol 2004 Goodpaster B, et al. Obes Res 2002; 10: 575 Vettor R, et al. Acta Diabetol 1997; 34: 61

28. Cedric Moro Adapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA Exercise physiology in obesity

29.  Suppressed lipolysis Exercise physiology in obesity Mittendorfer B, et al. Am J Physiol 2004; 286: E354

30. Adapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA Gondoni et al. Nutr Metab Cardiovasc Dis 2008 Exercise physiology in obesity  Cardiovascular disturbances

31. Exercise physiology in obesity  Cardiovascular disturbances Salvadori A, et al. J Clin Basic Cardiol 1999; 2: 229

32. Ardevol A, et al. Eur J Physiol 1998; 435: 495 Exercise physiology in obesity  Cardiovascular disturbances

33. Exercise physiology in obesity  Ventilatory abnormalities Satiago Lorenzo and Tony Babb Adapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA

34. Exercise physiology in obesity  Ventilatory abnormalities Satiago Lorenzo and Tony Babb Adapted from: Hansen D, Exercise therapy in adult individuals with obesity. 2013, Nova Science Publishers, NY, USA Could lower PaO2 during exercise

35.  Disturbed muscle function  Muscle overload during walking/running  Increased RPE Borg especially during weight-baring exercises Exercise physiology in obesity

36.  Disturbed muscle function  Lowered fat oxidation capacity Exercise physiology in obesity Percentage of plasma free fatty acid (FFA) uptake oxidized during basal and exercise (50% maximum O2 consumption). *Significantly decreased in extremely obese and extremely obese subjects after weight reduction (weight-reduced) compared with lean (P < 0.05). Houmard J A Am J Physiol Regul Integr Comp Physiol 2008;294:R1111-R1116

37.  Greater likelihood for development of orthopedic limitations  (knee) osteo artritis  Plantar heel pain (plantar fasciitis)  Carpal tunnel syndrome  Rotator cuff tendinitis  Low back pain Exercise physiology in obesity

38. Type 2 diabetes patients show different physiological responses to exercise as compared to healthy individuals Type 2 diabetes patients are often overweight/obese, so typical anomalies in exercise response which occur in the obese may be expected Exercise physiology in type 2 diabetes

39.  Substrate selection is altered

40. Boon et al. Diabetologia 2007; 50: 103-12 Whole-body substrate source utilisation at rest (a) and during exercise (b) and post-exercise recovery (c). Black, plasma NEFA; White, muscle and lipoprotein-derived triacylglycerol; Grey, carbohydrate in a and c, plasma glucose in b; hatching (b), muscle glycogen. *Substrate source oxidation significantly different from control group (p<0.05) † total fat oxidation significantly different from control group (p<0.05)

41. Exercise interventions in type 2 diabetes

42.  How to prescribe exercise?  Adapt the exercise modalities!  Exercise intensity  Session duration  Exercise frequency  Program duration  Addition of strength-training

43. Exercise intensity Van Loon LJ, et al. J Physiol 2001; 536: 295

44. Exercise intensity Hansen D, et al. Diabetologia 2008: 52: 1789-97

45. Exercise intensity Umpierre D, et al. Diabetologia 2013; 56: 242-51

46. Mitranun W, et al. Scand J Med Sci Sport 2013; e-pub ahead of print Exercise intensity

47. Session duration/volume  Assumption  Longer exercise sessions = greater effect  Greater decrease in plasma glucose levels in T2DM patients when cycling for 40 minutes at 70% VO 2peak compared with 40 minutes at 50% VO 2peak Sriwijitkamol A, et al. Diabetes 2007; 56: 836-48

48. Program duration  International guidelines  Minimal 2 months in order to detect clinical benefits  Elevated physical activity should be sustained after supervised program completion

49. Program duration Hansen D, et al. Sports Med 2010: 40: 921

50. HbA1 c months Cessation of exercise training Program duration

51. Exercise frequency  International guidelines  3 to 5 d/week  At start of programme: 3 days  After 4-6 months of exercise training: increase training frequency  On a regular base!

52. days Insulin sensitivity Exercise frequency

53. Umpierre D, et al. Diabetologia 2013; 56: 242-51 Exercise frequency

54. Addition of strength exercises  International guidelines  Strength training exercises should be added:  10-15 reps, 3 series, 65-70% 1RM

55. Cauza et al. Arch Phys Med Rehabil 2005; 86: 1527 Addition of strength exercises

56. Cauza et al. Arch Phys Med Rehabil 2005; 86: 1527 Addition of strength exercises

57. Hansen D, et al. Sports Med 2010: 40: 921

58. Exercise in type 1 diabetes: how?

60. Increased synthesis of epinephrine and growth hormone Increased glucose release by liver

61. Increase the medical safety of intervention in following conditions: Peripheral neuropathy and/or delayed wound healing = be alert to wounds and/or peripheral sensation disturbances Autonomic neuropathy = be alert to deregulated blood pressure Cardiovascular disease = rule out coronary and/or peripheral vascular disease Retinopathy = no high-intensity exercises Nephropathy = avoid high blood pressures ACSM & ADA. Med Sci Sports Exerc 2010; 42: 2282-303 How to maximize medical safety

62. Orthopedic screening – Diabetic hand syndrome – Dupuytren contracture – Trigger finger – Diffuse idiopathic skeletal hyperostosis – Charcot foot

63. How to maximize medical safety Check feet – Shoes: worn out or too narrow? – Feet: dermatologic risk factors

64. Glycemic control Start training session Glucose <75 mg/dl: consume monosaccharides Glucose <100 mg/dl: be alert for hypoglycemia Glucose >300 mg/dl: rule out keto-acidosis, no high-intensity exercise Risk factors for hypoglycemia during exercise Prolonged (>60 min), and/or intense exercise Exercise in fasting condition? Medication: sulfonyloreas, meglitinide, exogeneous insulin therapy During follow-up Regularly assess blood glucose content Always carry monosacharides with you Exercise in group ACSM & ADA. Med Sci Sports Exerc 2010; 42: 2282-303 How to maximize medical safety

65. Check prescribed medication – Cardioprotective drugs Diuretics – Dehydration and electrolyte imbalances when dosed too high Beta-blockers – Lowering in exercise HR – Lowers sensation of hypoglycemia Lipid-lowering medication – Statins could lead to myopathies

66. How to maximize medical safety Hansen D, et al. Phys Ther 2013; 93: 597-610

67. KineCoach project Prevalence of T2DM is rapidly rising T2DM is associated with many co-morbidities Exercise intervention is highly effective GP’s, cardiologists and endocrinologists often promote a healthy lifestyle to their patients But where can these patients follow medically safe and clinically effective exercise interventions?

68. KineCoach project Hansen D, et al. Phys Ther 2013; 93: 597-610

69. KineCoach project Hansen D, et al. Vlaams Tijdschr Diabetol 2013; 1: 10-12

70. KineCoach project Hansen D, et al. Phys Ther 2013; 93: 597-610

71. KineCoach project Hansen D, et al. Phys Ther 2013; 93: 597-610

72. KineCoach project Hansen D, et al. Phys Ther 2013; 93: 597-610

73. Contact: Dominique.hansen@uhasselt.be