Diabetes Flashcards
Definition of diabetes
WHO expert commitee on DM 1980
Diabetes is a state of chronic hyperglycemia that may result from many environmental and genetic factors often acting jointly
What is type 1 diabetes
diabetes.co.uk 2018
-auto immune disease directed at the pancreas which affects the beta cells of the pancreas resulting in an absolute deficiency of insulin
-trigger of auto immune response not specifically identified may be a toxin or virus
-genes play a role
-present underweight at diagnosis
4t’s symptoms
thirst, thinner, toilet, tired
what is type 2 dm
-average onset 60
-involves variable degrees of insulin secretion due to beta cell dysfunction and impaired insulin action ie secretion and uptake of insulin is impaired
-slower onset than 1 dm
sympoms often mild or absent initially so can go undiagnosed for many years
% of people with dm2 overweight
80% diabetes uk 2009
how does obesity cause 2dm
adipose tissue releases inflammatory chemical make body resistance
obesity triggers changes in body’s metabolism causes release of fat molecules into blood stream affect insulin sensitivity
prevalence of diabetes
diabetes.co.uk 2018 10% dm1 90% dm 2 -850,000 with 2 dm could be unaware diabetes uk 2017 3.7 million diagnosed with dm, 4.6 million including those undiagnosed nhs dpp, 22,000 die early in uk from dm IDF 2017 425 million worldwide, most 2dm due to ageing pop and obesity
treatment diabetes
diabetes.co.uk
diagnosis of diabetes
who criteria 2000
-random venous >11.1
-fasting plasma >7
ogtt >11.1
hba1c >6.5%
diagnosis of pre diabetes
hbaqc= 6-6.4
ogtt 7.8-11.1
fasting glucose 5.5 to 7
complications of diabetes
diabetes.co.uk
macra= cvd
mico= neph, neuro, reti,
complications of diabetes and glucose control
Diabetes control and complications trial 1993
-found that improving blood glucose control to a median HBA1C of 7% can reduce development and progression of mico comp by 35-76%
but improving blood glucose had no sig effect on cvd macro suggest important to control other risk factors
complications of diabetes and blood pressure control
UKPDS 1998 controlling BP has favourable effects on both macro and micro,
lowering bp to 144/82 sig reduced stroke 44%, heart failure and 37% micro complications
normal response and diabetes response to exercise reference
Robertson et al 2014
normal= decrease insulin, increase counterreg hormones, little blood glucose change as balance
dm 1 too much insulin= hypo versus too little insulin= ketosis
dm2 can get hypo if on meds such as insulin or su as otherwise respond normally as reduced hepatic glucose production if on su or insulin
reference pa enhances muscle insulin sensitivity
thorell et al 1995
what are the main complications for people exercising with dm
- fear of hypo
- hypo
- hyper
- mico and macra complication
reference for fear of hypo
younk, tate and davis 2009 fear of hypo causes overaeating to deliberately run a high BG before/during and after exercise thus the resulting hyper can increase HBA1C
what is a hypo
robertson et al 2014
-levels <4mmol/l shake,sweat,lip tingle,pale confused
-confuse with normal exercise response
-1dm or 2dm on meds
harder and longer activities and unfamiliar
hypo and youth reference
kelly hamilton and ridell 2010 hypo compromises sport performance by 20% and cognitive function and
spontaneous nature of pa in children ref
rowland 1998
hyperglycemia causes
type one only
2 situations not enough insulin or short term intensive activity so may need to let bg return to normal and inject insulin fast acting
pre-exercise asessment guidelines
ada 2016
- no current evidence that screening beyond the usual care dm reduces risk of exercise induced adverse events in asymptomatic individuals
- pre exercise med clearance no necessary in asymptomatic individuals recieveing dm care
sedentary time dm guidelines
coldberg et al 2016
- all adults particulatrly those with 2dm should decrease amount of time spent sitting
- prolonged sitting should be interrupted with light bouts of activity every 30 minutes for blood glucose benefits at least in adults with 2dm
- addition to other exercise
sb time evidence for dm
coldeberg et al 2016
- higher amounts of sedentary time are assoc. to increase mortality and morbidity mostly independent of mvpa
- in people with or at risk of developing 2dm, extended sedentary time is also assoc. to poorer glycemic control and clustered metabolic risk
- prolonged sitting interrupted by brief bouts of standing/ light pa every 20/30 mins improves glycemic control
van dijk etal 2013, dempsey etal2016
in adults with 2dm interrupted prolonged sitting with 15 min postmeal walk or 3min lightpa/ sra every 30 mins imrpoves glycemic control
pa recommendations for 2dm
coldberg et al 2016
- daily exercise or at least not allowing more than 2 days to elapse between exercise sessions is recommended to enhance insulin action
- combined aerobic and rt
- children meet norm pa guidelines
- structured lifestyle intervention incl.150 mins week and 5-7% weight loss
- flexibility and balance important for peripheral neuropathy
- increase daily (3-15 minutes) movement to reduce postprandial hyper and reduce SB
- Coldberg et al 2010 3x week, no more than 2 consecutive days, 40-60%, min 150 minutes a week large muscle group
- Coldberg et al 2010 Resistance training 2x week, non consec days, 50% 1pm mod 60-80% vid 5-10 exercises 10-15 reps, 1-4 sets
- Coldberg et al 2010 supervised training
- ADA 2016 for weight loss with 2 dm recommend 500-700kcal/ day energy deficit with reduced calorie diet and 200-300 min/week pa
- O’Halloran and Bhogal 2014 states gradually building up the number of steps to 10,000 steps a day and increasing to 15,000 steps a day in order to loose weight.
ronald et al 2004
duration insulin sensitivity not more than 72 hrs
pa guideline 1dm
coldberg
- youth and adults 1dm benefit from pa
- blood glucose responses to pa in all people with 1dm are highly variable, based on activity type and timing
- additional card/ insulin reduction required to main balance during and after
- insulin can use either basal bolus or insulin pump
- use CGM to detect hypo
general recommendation for pa
coldberg
- asssess unecessary
- same guidelines as adults norm 150 spread over 3 days no more than 2 consec
- encourage increase incidental to pa
- to gain more health benefit supervised over non
- behaviour strategies
- tolerable step targets
- flexibility2-3x week older
pa recommendation avoid hypo
robertson etal 2014
- activity
- carbs before and after hypo 24hrs
- avoid exercise when insulin peak
- alter insulin dose
- CGM
- subcut injection
- dont inject into site used in pa
- nocturnal hypo coldberg
- short sprint in aerobic
- insulin pump nagi and gallen 2010
pa recommendation for specifc complications
coldberg nagi and gallen
- peripheral neuropathy
- autonomic neuropathy: heat and bp
- retinopathy-avoid bp increase
- cvd keep <10bpm angina onset
- nephropathy exercise undertaken safely but fine
pa references evidence for 2dm PREVENTION
- Tuomileto et al 2001
- Knowler et al 2002
- healthier you 2016
- Aguiar et al 2014
pa and 1dm evidence
1.cuenca garcia
2. macmillan et al 2014
3, chimen et al 2012
4.quirk et al 2014
5. yardley et al 2014
6. waden et al 2015
pa and 2dm evidence
- dempsey et al 2016
- thomas et al 2006
- Umpierre et al 2011
- Avery 2012
tuomileto et al 2001
522 people IGT
Ig individualised advice on pa, diet and weight
cg standard care alone
3.2 yr follow up
progression to 2dm 58% lower in IG compared to cg and mean body weight diff higher 4.2 versus 0.8
knowler et al 2002
3 groups placebo, drugs metformin x2, and lifestyle advice group 16 week 7% wl aim
3234 IGT participants
lifestyle 58% lower and 31% lower in pharama compared to placebo group
1/2 ethnic minority
aguiar et al 2014
- sr and ma of multi component lifestyle intervention
- diet aerobic and rt intervention commbined
- 12 months median, follow up 18 month
- on average asked to perform aerobic exercise 5xweek, 157.5 mins week, RT 2.3 days week, average duration 90 mins a week
- MA sig reduction in weight, fast placma g in IG over CG
- concluded multi component at least 150 mins, 60 mins rt effective induce weight loss and diet
cuenca garcia et al 2012
using accelerometer found mvpa associated to better glycaemic control and accounted for 30-37% of variance in PA
young people 1dm97
macmillan et al 2014
sr
11 studies included youth with dm 1
intervention ranged 8 to 24 weeks, most 12 weeks
-7 aerobic,3 combined 1 pilates
-MA found benefits to HBA1C were associated to longer programs >12 weeks, more frequent >3 days a week and longer duration >60 minutes and include combined aerobic and RT
limitations: small sss, 2 reported adherence to intensity
chimen et al 2012
aerobic training in 1 dm increases crf, improve lipid, endothelial function
found increase of up to 27% vo2 reported in vo2 from supervised pa program
-depending on intensity of intervention reduces HBA1C about 4.2mmol/s
-incidence of depression 3x higher and improves well being
-both rt and endurance improved insulin sensitivity up to 23 %
quirk et al 2014
st and ma 23 studies youth with dm 1 interventions: 2-29 week ,modal 12, 30-120 mins , 1-5x, combined or aerobic 65-74% for mod, >75% vig RESULTS of MA -hba1c= -0.52 mean diff -no diff in insulin dose -lipids mean diff -0.91 for total cholesterol and bmi decreased
yardley et al 2014
sr and ma adults 1dm
6 rct
2xweek to daily, 50-90% 20-120 mins, 2month min
combined or aerobic
RESULTS
decrease -0.78% compared to controls
exercise training improved CRF by 3.45 ml.kg.min compared to control
but poor method reporting with withdrawal and concealment hard to ascertain risk bias
waden et al 2015
prospective study
6.4 yrs follow up
total amount of leisure time pa not assoc. to progression of renal status
but demonstrated that intenstiy and freq may be with higher intensity and >2 x week lower progression rate
but self report data for intensity
dempsey et al 2016
sb in 2dm adults
3 groups SIT, LWA 30 mins 3min walk, SRA, 30 mins resistance.
done for 8 hours 3 separate dats
only 24 participants, longer effects needed
-compared to SIT both activity sig attenuated acute postpranidal glucose, insulin, cpep and trig response.
sit 24.2, lwa 14.8 and sra 14.7 mmol.l
umpierre et al 2011
sr and ma
-pa advice versus structured exercise
47 RCT
PA >12 WEEKS
compared to control groups
aerobic 0.73% resistance 0.57% and combined 0.71% hba1c
-structured exercise >150 mins assoc to larger decrease -0.89%
pa advice no change
pa +diet advice -0.58% change
quality of studies low increase risk of bias
thomas et al 2006
cochrane review 2dm 14RCT exercise vs none 8-12 week duration 3 sessions per week, non-consec aerobic and RT mix either progressive rt or mod aerobic RESULTS -compared to cg the ig sig improved glycaemic c as hba1c -0.6& - decrease visceral adipose tissue with exercise and subcut -increase insulin response -decrease plasma trig primary studies none reported blinding 7. Found improvements in glycaemic control achieved from low to high intensities no study reported adverse events
avery 2012
sr and ma
behavioural intervention 2dm
17 RCTs
behavioural showed statistically sig increases in objective and self-monitoring pa
-sig improved hba1c and bmi
->4 weeks duration on free living pa and exercise
-hba1c 6month -0.33, 12 -0.33 & 24 -0.56%
found at least 10 diff behaviour change techniques assoc. to clinically sig improvement in hba1c >0.3%
esp. prompting generalization of a target behaviour, prompts follow up, prompt goals review, social support, time management and problem solving with identifying barriers
hamman et al 2006
found that for every kg of weight loss it reduced the risk of developing type 2 diabetes by 16% in participants with a bmi of >24
ahn and song 2012
a. Tai chi on exercise control, neuropathy, balance and hrqol in patients with 2dm and neuropathy
b. 59 dm patients with neuropathy
c. 1 hr tai chi, 2x week for 12 weeks
d. 34% drop out rate
e. Compared to a control group HbA1c was sig better, balance, neuropathic symptoms and some dimension of qol
morrison et al 2010
a. Balance training as 2dm are at increase risk falling due to impairment in posture and gait
b. Small sample size
c. Older adults with 2dm
d. 6 week 3x week exercise program consisting of balance posture and resistance strength of 1-2 sets of 10-12 reps
e. Dm individuals had a higher fall risk score compared to CG
f. But dm group showed sig improvement in leg strength, faster reaction time, decrease sway and consequently reduced falls risk after 6 weeks
jelleyman et al 2016
a. High intensity inverval training on glucose and insulin
b. Meta analysis
c. Either aerobic interval, sit or hit
d. Compared to control group and to continuous training there was a reduction in insulin resistance,
e. Compared to control group HBA1C decreased 0.19% and body weight decreased 1.3 kg
f. Participants with 2dm exepericed reduction in fasting glucose -0.92mmol l compared to control group
g. There were more exercise related injuries reported in HIIT than control but limited reporting
qiu et al 2014
a. Systematic review and meta analysis of walking and 2dm
b. 18 studies
c. Walking sig decreased HbA1c by 0.5%
d. Supervised walking assoc. to greater pronounced decrease in HbA1c -0.58 whereas non-supervised walking was not
e. Non supervised but with motivational strategies is effective in decreasing HBa1C -0.53%
f. Walking also sig reduced body mass, lowered BP and changed HDL or LDL cholesterol
g. Most overweight so walking only option
