Diabetes Physical exercise advice & Pharmacological Management Flashcards
What are the physical activity recommendations for patients with diabetesÉ
- TRY TO DO a minimum of 150 minutes of moderate-to vigorous-intensity aerobic exercise per week.
- INCLUDE resistance exercise (strength training) ≥ 2 times a week. - SET physical activity goals and INVOLVE a multi-disciplinary team if available.
- MINIMIZE uninterrupted sedentary time.
Why is physical activity recommended for people with diabetes?
physical activity improves insulin sensitivity - improved glucose uptake by the muscles - helps to reduce glycemia - other benefits: CVD prevention, decreased risk of HTN
What should be done before prescribing exercise? Why?
Assess for conditions that can predispose to injury before prescribing an exercise regimen: • Neuropathy (autonomic and peripheral) • Retinopathy • Coronary artery disease–resting ECG and possibly exercise stress test • Peripheral arterial disease
What are the steps of physical assessment tool?
STEP 1: PRE-ACTIVITY SCREENING Does your patient currently have symptoms of angina that would limit participation in physical activity (such as chest pain or severe pressure on physical exertion)? STEP 2: PHYSICAL ACTIVITY LEVEL AND PARTICIPATION Step 3: Physical activity program recommendations
Can more activity be prescribed?
If the patients is succeeding at being physically active, duration of exercise can be increased followed by a progression in intensity Provided absence of angina or other medical issues
How often should physical activity tool be used?
reassessment should be carried out every 6-12 months
Aerobic exercise advise
• Start by walking at a comfortable pace for as little as 5 to 15 minutes at one time • Gradually progress over 12 weeks to up to 50 minutes per session (including warm-up and cool down) of brisk walking • Alternatively, shorter exercise sessions in the course of a day, e.g., 10 minutes 3 times a day after meals, can replace a single longer session of equivalent length and intensity
Resistance exercise advise
• Choose 6 to 8 exercises targeting the major muscle groups: arms, chest, back, legs, abdomen. • Gradually increase the resistance until you can only perform 3 sets of 8 to 12 repetitions for each exercise, with 1 to 2 minutes of rest between sets. • When beginning resistance exercise, it is best to receive initial instruction and periodic supervision by a qualified exercise specialist, to maximize benefits and minimize risk of injury.
Interval exercise advise
• Exercise performed in intervals, alternating between higher-intensity and lower-intensity, can shorten total exercise duration, increase fitness gains, and increase variety. • For example, try alternating between 3 minutes of faster walking and 3 minutes of slower walking. • High intensity interval training is also an option. • For example, alternate between 30 seconds at very high intensity and 90 seconds at low intensity.
What is an alternative recommended form of exercise that has additional benefits?
Exercise in the water can have similar benefits as other forms of exercise and help minimize barriers from conditions such as osteoarthritis. • Exercise in the water can include walking briskly in the water, swimming or classes that include a variety of exercises
Which tools should be used by people with diabetes during exercise? How should they be used?
Encourage people with diabetes to self-monitor physical activity with a pedometer or accelerometer. Ask them to record values, review at visits, set step count targets, and formalize recommendations with a written prescription
What is the advise in regards to sedentary time?
It is best to avoid prolonged sitting. Try to interrupt sitting time by getting up briefly every 20 to 30 minutes
How can recommending exercise be made more serious/work more effectively?
Give the exercise recommendation in the form of prescription
What is the max duration for sedentary recreational time per day>
no more than 2h per day
Immediate benefits of aerobic exercise?
- Lower your blood glucose within 1h - Improve your mood, sleep patterns and energy level - Increase the effectiveness of insulin your body makes or the insulin your doctor prescribes for you
Long-term benefits of aerobic exercise?
• Improve your blood glucose control • Reduce your body fat • Help keep your pancreas, kidneys, eyes and nerves healthy • Reduce the risk of heart attack, stroke and death
Apart from exercise, what is another physical activity-related prescription
Sample Step Count Prescription
ABCDES3^ of Diabetes Care
A • A1C – optimal glycemic control (usually ≤7%)
B • BP – optimal blood pressure control (<130/80)
C • Cholesterol – LDL <2.0 mmol/L or >50% reduction
D • Drugs to protect the heart
E • Exercise / Healthy Eating
S • Screening for complications
S • Smoking cessation
S • Self-management, stress and other barriers
What are the possible control methods of A of ABCDES^3 of diabets
Controlled both via lifestyle changes and medications
What are the drugs to protect the heart?
A – ACEi or ARB
S – Statin
A – ASA if indicated
SGLT2i/GLP-1 RA with demonstrated CV benefit if type 2 DM with CVD and A1C not at target
Which diabetes type requires insulin injection?
mostly done in T1DM which requires insulin therapy
the more advanced cases of T2 also require insulin therapy
What ar the types of insulin therapy in type 1 diabetes?
BASAL – BOLUS INJECTION THERAPY
Bolus insulin at meal times + basal insulin once or twice a day
or
CONTINUOUS SUBCUTANEOUS INSULIN INFUSION
“insulin pump therapy” with continuous subcutaneous infusion of insulin via a catheter
diabetic tips and reasons
Intake tips for veggies, protein sources, oils and diets
Eat more vegetables. These are very high in nutrients and low in calories.
- Choose lean animal proteins. Select more vegetable protein.
- Select plant oils such as olive and canola, and nuts instead of animal fats.
- Include low-glycemic-index foods such as legumes, whole grains, and fruits and vegetables.
- Consider learning about counting carbohydrates, and different types of eating patterns (e.g. Mediterranean, DASH)
when you see a registered dietitian
How fast is the insulin response to ingesting a meal
Rapid, almost instant
How many injections does basal insulin involve?
1
Insulin levels
bolus vs basal
Conventional vs intensive insulin therapy
intensive insulin therapy
- recommended the most, but implies more injections
- some people don’t like injections
conventional insulin therapy
- Mix of rapid acting and moderately rapid acting insulin such that the patent in inject only twice a day
goal: to cover glucose peaks as much as possible
Human vs analogue premixed therapy
Human premixed: covers part of breakfast and lunch; second injection covers part of the dinner;
- with this type we see that there are still periods of hyperglycaemia (when grey zone is above the red)
Analogue premixed: better at covering the whole breakfast and dinner; lunch is not covered
- less hyperglycaemia through out the day, but not as good as having 4 injections
Types of insulin table
advantages of continuous glucose monitoring vs SMBG
If testing red dotes only-> patient would think that he is doing just fine
hypergycemia would be compensated by hypoglycemia -> hypoglycemia will not be detected
Antihyperglycemic agentsClass, generic name, mechanism
How do incretin mimetics work?
GLP-1 (glucagon like peptide-1) is an incretin that is secreted by the intestine afetr inhestign food
- it’s role is to syimlate insulin release and inhibit glucagon release
both will contribute to lowering of blood glucose
- Slows gastric emptying to lower blood glucose
- Increases satiety to help to control weight
GLP-1 agonist drugs will promote the effect of GLP-1
DPP-4 inhibitor will inhibit DPP-4 whihc is an enzyme that degrades GLP-1-> GLP-1 remains in the circulation for lngr period
Intervention flowchart for T2DM
when T2Dm is first diagnosed, the basis of treatment is lifestyle intervention (nutiriton, physical actibity and weight managment if needed to r4eas healthy weight
1st step of medical intervention- metformin
metformin prescription decision is made based on Hb A1C levels
If the A1C is less than 1.5% above the patient’s target A1C, if they are not at glycemic target within 3 months of healthy behaviour interventions, metformin should be started or increased.
If the A1C is greater than or equal to 1.5% above target A1C, metfomin should be started immediately. A second concurrent antihyperglycemmic agent antihyperglycemic agent should be considered.
If the patient has symptomatic hyperglycemia (polyuria, polyphagia, polydipsia) and/or metabolic decompensation, insulin should be initiated alone or in combination with metformin. This includes patients with dehydration, diabetic ketoacidosis or hyperosmolar hyperglycemic state.
asses in 3 month whether the glycemic target has been reached
Clinical cardiovascular disease is defined as history of myocardial infarction, coronary artery disease on angiography, unstable angina, stroke, peripheral artery disease)
For many patients, avoidance of hypoglycemia and/or weight gain with adequate glycemic efficacy are important considerations. For these patients, an appropriate choice of agent includes a DPP-4 inhibitor, GLP-1 receptor agonist of SGLT2 inhibitor.
Intervention flowchart for T2DM with absence of CVD
Drugs compared by:
Effect on CVD Outcomes
Hypo- glycemia
Weight
Relative
A1C Lowering when added to metformin
Other therapeutic considerations
Cost
- best ones are GLP-1 agonists and SGLT2 inhibitors
- Decrease the risk of hypoglycaemia, help reduce weight, reduce the risk of CVD, good at lowering Hb A1C
- but are costly and injectable
- the risk of hypoglycemia is highest with insulin and insulin secretagogues.
- ]GLP-1 receptors and SGLT2 inhibitors are associated with weight loss. DPP-4 inhibitors are weight neutral. Insulin, TZD’s and insulin secretatogues are associated with weight gain.
- The greatest A1C lowering when added to metformin are seen with GLP-1 receptor agonists, SGLT2 inhibitors and insulin.
Effects of drugs on weigth
its never a massive weight gain or loss, but still important to let the patient know
Drug-nutrient interactions or concerns
