Lecture 5 - Diabetes & Exercise Flashcards
Diabetic Ketoacidosis [DKA]
Type 1 Diabetes
-poor control and low insulin
Ketones
- ineffective use of insulin
- cant use glucose effectively
- high fat metabolism
Tested by urine dipstick test
- normal healthy around 0.1mmol/L
- patients with diabetes - can be as high as 25mmol/L
Symptoms
-abdominal pain, nausea, vomiting, rapid or deep breathing, and sweet- or fruity-smelling breath
Exercise is a contraindication
Treatment Pharmacological Therapy:
Type 2 DM:
- sulfonylurea
- biguanides
- meglitinides
- thiazolidinediones Glitazones
- a-Glucosidase inhibitors
- insulin
Type 1 DM:
-insulin
Describe Sulfonylureas
Pharmacological effect:
-Stimulate the pancreatic secretion of insulin
Classification:
-First Generation= e.g. tolbutamide, chlorpropamide, and acetohezamine
= lower potency, more potential for drug interaction and side effects
-Second Generation= e.g. grime-iridescent, glipizide, and glyburide
= higher potency, less potential for drug interactions and side effects
Efficacy:
- HbAc1: 1.5 -1.7% reduction
- FPG: 50-70 mg/dL [2.8-3.9 mmol/L] reduction
- PPG: 92mg/dL [5.1 mmol/L] reduction
Adverse Effect:
- hypoglycaemia
- hyponatremia
- weight gain
Describe Meglitinides:
- Repaglinide [prandin]
- Nateglinide [Starlix]
Pharmacological effect:
-stimulation of the pancreatic secretion of insulin [the insulin release is glucose dependent and is decreased at low blood glucose]
Adverse effect:
- risk of hypoglycaemia
- possible upset tummy
Describe Biguanides
Merformin [Glucophage]
Pharmacological effect:
- reduces hepatic glucose production
- increases peripheral glucose utilisation
Adverse effects:
-nausea, vomiting, diarrhoea, and anorexia
Glitazones [PPARg Agonists]
Class as Thiazolidinediones
Pharmacological effect:
- Reduces insulin resistance in the periphery [sensitive muscle and fat tot the action of insulin] and possibly in the liver
- the onset of action is sow taking 2-3months to see the full effect
- edema and weight gain are the most common side effects [no hepatotoxicity]
A-Glucosidase Inhibitors
- Acarbose
- Miglitol
Pharmacological effect:
-Prevent the breakdown of sucrose and complex carbohydrates [the net effect is to reduce postprandial blood glucose rise, slow absorption of starch, disaccharides and polysaccharides from GI tract]
Insulin: Onset and duration of effect
Changing the properties of insulin preparation can alter the onset and duration of action
- lispro: [monomeric] absorbed to the circulation very rapidly
- aspart: [mono-and dimeric] absorbed to the circulation very rapidly
- regular: [hexameric] absorbed rapidly but slower than lispro and aspart
Lente Insulin:amorphous precipitate of insulin and zinc and insoluble crystals of insulin and zinc. Releases insulin slowly to the circulation
NPH: releases insulin slowly to the systemic circulation
Insulin glargine: prepared by modification of the insulin structure. Precipitation after injection to form microcrystals that slowly release insulin to the systemic circulation.
Insulin: onset and duration of effect
Rapid-acting insulin - e.g.insulin lispro and insulin aspart
Short-acting insulin- e.g. regular insulin
Intermediate-acting insulin - e.g. NPH and Lente Insulin
Long-acting insulin - e.g. Insulin Glargine
Insulin: Adverse effects
Hypoglycaemia : Treatment
- patients should be aware of symptoms of hypoglycaemia
- oral administration of 10-15g of glucose
- IV dextrose in patients with lost consciousness
Insulin: Methods of insulin administration
Insulin syringes and needles
Pen-sized injectors
Insulin pumps
How does exercise help fight diabetes?
Glut-4 is transported to the cell wall to transport glucose across the cell wall.
Name 8 benefits of Exercise for patients with Type 1 diabetes:
- Lower blood glucose during and after exercise
- Improved insulin sensitivity and decreased insulin requirement
- Improved lipid profile
- decreased triglycerides
- slightly decreased LDL-C
- increased HDL-C - Improvement in mild-to-moderate hypertension
- increased energy expenditure
- adjunct to diet and weight reduction
- increased fat loss
- preservation of lean body mass - Cardiovascular conditioning
- Increased strength and flexibility
- Improved sense of well-being and QOL
Name the 5 risks of exercise for patients with Type 1 Diabetes
- Hypoglycaemia:
- exercise induced hypoglycaemia
- late-onset post exercise hypoglycaemia >3h after exercise - Hyperglycaemia after very strenuous exercise [>80% VO2max]
- Hyperglycaemia and ketosis in insulin-deficient patients
- Precipitation of exacerbation of cardiovascular disease:
- angina pectorals, MI, arrhythmias, sudden death. - Worsening long term complications of diabetes
- proliferate retinopathy
- nephrophathy
- peripheral neuropathy
- autonomic neuropathy [decreased cardiovascular response to exercise, max aerobic capacity, impaired response to dehydration, postural hypotension, altered GI function]
Suggested strategies to avoid Hypo-or-Hyperglycaemia during and after exercise.
- Adjustments to the INS regimen
- Take INS >1h before exercise. If <1h before exercise, inject in non-exercising part of body.
- Decrease dose of both short- and intermediate-acting INS before exercise
- Alter daily INS schedule - Meals and supplemental feedings
- Eat 1-3h before exercise and check BG is in safe range [100-250mg/dl] [5.6-13.8mmol/L] before exercise
- Eat CHO < every 30min during vigorous or long duration exercise
- Increase food intake for up to 24h after exercise [depending on intensity and duration] - Self-monitoring of blood glucose and urine ketones
- Monitor BG before, during and after Ex to determine need for and effects of changes in INS dosage and feeding schedule
- Delay exercise if BG < 5.6mmol/L or >13.9mmol/l & ketones are present. Use supplemental feedings or INS to correct BG & metabolic control before starting exercise - Determination of unique metabolic responses
- Learn individual BG responses to different types, intensities, and conditions of exercise
- Determine Effects of Exercise at different times of day and effects of training on BG.
Recommendations for exercise testing:
Use CAD protocols [low Level treadmill protocols or cycle or arm ergometer modes] in people who:
- Have type 1 diabetes and are >30 yr;
- Have had type 1 diabetes >15yr;
- Have type 2 diabetes and are >35yr;
- Have type 1 or type 2 diabetes and one or more of the other CAD risk factors:
- Have suspected or known CVD; and/or
- Have any microvascular or neurological diabetic complications
ESSA exercise Prescription Guidelines
- Patients with T2D or pre-diabetes should accumulate 210min.wk of moderate intensity exercise, or
- 125min.wk of vigorous intensity exercise with no more than 2 consecutive days without training
- It’s further recommended that 2 or more RT sessions per week should be included in the 210 or 125min.wk of moderate or vigorous ex, respectively [2-4 sets of 8-10 reps]
- Bouts as low as 10 min performed a few times per day have been shown to be effective
- No more than 2 consecutive days without exercising
Special considerations for exercise:
Autonomic neuropathy common; may be associated w/ silent ischaemic, postural hypotension, and/or blunted HR response to exercise
Peripheral neuropathy common; may cause numbness, tingling in extremities, Charcot’s joint, and reduced balance
Microvascular complications may be affected by excessively high BP
PVD may result in intermittent claudication and/or infections or ulcers in lower extremitities w/ poor wound healing
Diabetic with Peripheral Neuropathy
Peripheral neuropathy may results in loss os sensation in the feet
Repetitive exercise on insensitive feet can lead to ulceration & fractures
Limit weight bearing exercise [treadmill, prolonged walking, jogging, step exercise]
Alternative exercises are: swimming, bicycling, arm exercise, chair exercise]
Use proper shoes, and always monitor the feet.
Diabetic with autonomic neuropathy
This condition ma limit exercise capacity & increase the risk of CV event during exercise
Hypotension and hypertension are more likely to develop after vigorous exercise
Those patients may have difficulty with thermoregulation:
- Avoid exercise in hot or cold environments
- Encourage adequate hydration
Exercising wiht Diabetes complications
If you have diabetic complications:
- an exercise stress test is recommended
- don’t consider diabetes a barrier to exercise
Exercising with Heart Disease:
Caution:
- very strenuous activity
- heavy lifting or straining
- exercise in extreme cold or heat
Choose:
- moderate activity such as walking, swimming, biking, gardening
- moderate lifting, stretching
Exercising with Hypertension [high blood pressure]
Caution:
- very strenuous activity
- heavy lifting or straining
Choose:
- moderate activity like = walking, weight lifting with light weights, stretching
Exercising with Retinopathy [eye disease]
Caution:
- strenuous exercise
- heavy lifting and straining
- high impact aerobics, jogging
- bending your head below your waist - toe touching
Choose:
- moderate, low-impact activities [walking, cycling, water exercise]
- moderate daily chores that don’t require lifting or bending your head below your waist
Exercising with Nephropathy [kidney disease]
Caution:
- Strenuous activity
Choose:
- Light to moderate activity like walking, light housework, gardening, water exercise.
Exercising with Neuropathy [Nerve disease]
Caution:
-weight bearing, high impact, strenuous, or prolonged exercise [jogging/running, step exercise, jumping, exercise in heat/cold]
Choose:
- low impact, moderate activities [biking, swimming, chair exercises, stretching,light to moderate daily activities]
