Elaine HibbertJones - PowerPoint PPT Presentation

Title: Elaine HibbertJones


1
Physical Activity and Diabetes

• Elaine Hibbert-Jones
• Chief Diabetes Dietitian
• Royal Gwent Hospital
• Newport

2
Plan of session

• Metabolic and physiological responses to
  exercise
• Energy production and fuels for exercise
• Glycaemic control
• Diet for exercise
• Hydration
• Exercise and Type 2 diabetes

3
What is exercise?

• Exercise means different things to different
  people and for competitive sport involves many
  hours of training

4
Team Sports

• A team player e.g. football may train 2-3 times a
  week and play a match

5
Individual sports

• A gymnast may train 2-3 hours a day, 5 times a
  week

6
Recreational activities

• Some people may only manage to exercise
  occasionally

7
Role of the Health Care Professional

• To encourage exercise in all people with
  diabetes.
• Enable people with diabetes to take part in the
  physical activities and sports they want to
• Enable them to undertake these activities safely

8
Advantages of physical activity and Type 2
diabetes

• Adjunct to diet for initial weight loss
• Aid to maintain weight loss
• Loss and redistribution on abdominal fat
• Improved glycaemic control
• Management of hypertension
• Management of dyslipidaemia
• Improvements in general well being
• Nagi N in Exercise and sport in diabetes 2005

9
Physical activity and Type 1 diabetes

• In general the advantages of physical activity
  in Type 1 Diabetes relate more to the protective
  cardiovascular effects and psychological well
  being rather than improvements in glycaemic
  control..

10
Restricted Sports
11
Evaluation of patient before exercise

• Medical examination
• screen for presence of macro and microvascular
  complications
• Cardiovascular disease
• Peripheral artery disease
• retinopathy
• Nephropathy
• Neuropathy

12
The challenge

• To adjust the therapeutic regimen, both
  insulin and nutrition therapy, to normalise blood
  glucose levels and optimise performance.
• Successful management requires an
  understanding of-
• Food composition
• Fuel regulation before, during and after exercise

13
Metabolic and physiological responses to exercise
14
Physiological responses

• Increase in heart rate, cardiac output,
  respiratory ventilation and oxygen consumption
• Use of substrates in muscle and liver to provide
  energy
• Hormonal and sympathetic nervous system effects
  on the liver and adipose tissue

15
Energy substrates used during exercise
16
Energy needs

• The way energy is used during physical activity
  affects blood glucose levels
• How fast you move, how much force you produce and
  how long the activity continues affects the
  overall needs of the working muscles

17
Energy production

• Carbohydrate, fat and protein are metabolised by
  the body to produce Adenosine Triphosphate (ATP)
  the high energy bonds found in muscle
• ATP is the universal energy carrier
• ATP is not stored in sufficient amounts in the
  body so must be constantly regenerated

18
The ADP/ATP Cycle
ATP
Energy Requiring Processes
Fuel Oxidation
ADP
19
Energy production

• To deal with this the body has 3 energy systems
  to supply the body with ATP

20
Energy pathways and ATP production

• ATP - Creatine Phosphate (CP) System
• The Glycolytic System
• The Oxidative System

21
CP provides energy to rapidly replenish ATP
during 6-8 seconds of all out effort
 
22
Anaerobic and aerobic glycolysis
Glycogen
Pyruvate
With Oxygen
Without Oxygen
Lactate
Carbon Dioxide Water
23
Anaerobic glycolysis
 
24
Anaerobic glycolysis

• Provides energy very rapidily
• For high intensity activity of 1 - 3 mins
• Glycogen stores rapidly depleted
• Inefficient, provides 2 ATP per molecule of
  glucose

25
Aerobic oxidation of Carbohydrate and Fat
 
26
Aerobic glycolysis

• Slower process than anaerobic glycolysis
• Provides energy for less intensive, longer
  duration activities eg swimming, running, cycling
• More efficient, provides 18 ATP per molecule of
  glucose

27
Fuels used in 100m sprint
100
Anaerobic glycolysis
50
Contribution of Fuel ()
Creatine phosphate
0
50
100
Distance (m)
28
Fuels used in 200m sprint
Aerobic glycolysis
100
Anaerobic glycolysis
50
Contribution of Fuel ()
Creatine phosphate
0
100
200
Distance (m)
29
Fuels used in 1500m run
Aerobic glycolysis
100
Aerobic glycolysis
50
Contribution of Fuel ()
CP
CP
Anaerobic glycolysis
0
800
1500
Distance (m)
30
Fuels used in 10000m run
100
Aerobic glycolysis
50
Contribution of Fuel ()
CP
Anaerobic glycolysis
0
5000
10000
Distance (m)
31
The contribution of fuels used during exercise
32
Energy production

• This can be broken down into 3 stages

33
Short duration lt10minutes

• ATP-PCr system
• Breakdown of muscle glycogen i.e. glycogenolysis

34
Duration gt 10 mins

• Muscle glycogenolysis
• Blood-bourne glucose and fatty acids
• Increase in glucose uptake by working muscle (can
  occur in the absence of insulin)

35
Endurance exercise gt90 minutes

• Large proportion of energy from fat metabolism
• Coincides with decrease in glycogen stores
• Depletion of glycogen stores is highly correlated
  with exhaustion

36
Energy regulation during exercise
100
Free fatty acid uptake
Muscle glycogen
Fuel Contribution to Total 02 Uptake ()
50
Blood glucose uptake
0
2
4 hrs
1
0
3
Glycogen
Glucose FFA Uptake
? FFA
? Glucose Uptake
37
Adaptation of endocrine system to exercise

• Insulin concentration decreases
• Counter-regulatory hormones increase
• Cortisol
• Glucagon
• Catecholamines
• Growth hormone
• Glucose released from liver and fatty acids from
  adipocytes

38
Hormones with glucose raising effects during
exercise
39
Adaptation of endocrine system to exercise

• Insulin inhibits glycogenolysis and
  gluconeogenesis and reduces the release of fatty
  acids from adipocytes
• Counter-regulatory hormones induce the opposite
  effect

40
Consequences of hormonal response to exercise
Amino acids
Rise in adrenaline Glucagon
Liver

Blood Glucose
-
Muscle
Glycerol and FFA increased
-
Fall in Insulin Rise in adrenaline and SNS
stimulation
Adipose tissue

41
Consequences of hormonal response to exercise
Amino acids
Rise in adrenaline Glucagon
Liver

Blood Glucose
-
Muscle
Glycerol and FFA increased
-
Fall in Insulin Rise in adrenaline and SNS
stimulation
Adipose tissue

But if Insulin fails to decrease then more blood
glucose will be taken up by tissues and less FFA
and glycerol release potential for hypoglycaemia
42
After exercise

• Hormone concentrations return to normal levels
• Lipolysis ends and glycogen stores can be
  replaced
• Increased muscle insulin sensitivity and higher
  glucose uptake

43
Altered response to exercise in type 1 diabetes

• No inhibition of insulin release
• Potential increased absorption of insulin due to
  increased body temperature and blood flow
• Reduced awareness of hypoglycaemia and lowered
  glucagon and adrenaline responses to low glucose
  in some patients
• Intense exercise produces hyperglycaemia

44
Regular exercise

• Increases sensitivity of insulin receptor for
  insulin
• Increases number of insulin-dependent glucose
  transporters (GLUT4)
• Increased glucose uptake

45
Insulin levels and exercise

• The level of circulating insulin before and
  during exercise is critical to exercise
  performance and prevention of fatigue

46
Blood glucose response and circulating insulin
levels
47
What should the level of glucose be before
exercise?
48
Variables that affect blood glucose response to
exercise

• Pre exercise blood glucose levels
• Type, duration and intensity of exercise
• Fitness
• Environmental conditions e.g. heat or cold
• Hydration status

49
General exercise guidelines for Type 1 diabetes

• before exercise
• Blood glucose gt 14 mmol/l ketones
• Avoid exercise
• Blood glucose gt 17 mmol/l no ketones
• exercise with caution
• Ingest carbohydrate if blood glucose level
• lt 5.5 mmol/l

ADA 2003
50
Local Guidelines

• Blood glucose lt 7.0 mmol/l
• Ingest carbohydrate
• depending on duration/type of exercise
• Blood glucose 7.0 -10 mmol/l
• Consider additional carbohydrate
• Blood glucose 10 -17mmol/l
• Consider bolus of rapid acting analogue
  insulin

51
Blood glucose homeostasis in Type 1 diabetes

• Insulin concentration is set by the time elapsed
  from the last injection
• This lack of insulin regulation can lead to
  frequent metabolic imbalances during exercise

52
Insulin concentrations and glycaemia in Type 1
diabetic patients during moderate exercise
Francescato et al. Metabolism 2004531126-30
53
Ups and downs of Insulin

• It is essential to know when the insulin peaks in
  order to determine the blood glucose response to
  exercise and the need for supplemented
  carbohydrate in order to prevent exercise induced
  hypoglycaemia

54
Human Insulin Action Times
55
Prevention of hypoglycaemia

• Reduce insulin
• Have additional carbohydrate
• Both

56
Insulin Lispro recommended Dose Reduction
Rabasa-Lhoret et al, 2001
57
Hypoglycaemia and treatment options
Plt0.01
Plt0.01
Grimm et al Diabetes Metab 200430465-70
58
Extra CHO for exercise
Grimm et al Diabetes Metab 200430465-70
59
Diet for exercise
60
Carbohydrate

• The most important fuel for working muscles
• CHO should provide 55-70 of total energy
• Limited storage as glycogen in liver and muscle
• Stores rapidly depleted during high intensity
  exercise e.g. sprints
• Stores gradually depleted in endurance exercise
  over several hours
• Insulin is necessary for repletion of stores

61
Carbohydrate recommendations for training
Stear 2004
62
Calculating your carbohydrate requirement
63
DAFNE approach

• Patients are taught to match their insulin dose
  to their carbohydrate intake on a meal by meal
  basis
• Emphasis on self-management
• Using this process is very useful when
  determining CHO requirement and changes to
  insulin regimen.

64
Additional CHO may be needed at 4 different times

• 2-3 hours before exercise
• 20 - 30 minutes before exercise depending on pre
  exercise blood glucose level
• During exercise for exercise longer than 30
  minutes
• After exercise for maintenance of blood glucose
  level, prevention of hypoglycaemia and for
  refuelling of glycogen stores.

65
Pre exercise carbohydrate meal

• Low glycaemic index type 2 - 3 hours before e.g.
• pasta
• porridge
• granary/wholegrain bread
• fruit e.g. apple, under ripe banana
• milk/yoghurt
• basmati rice

66
Pre exercise carbohydrate snack

• High glycaemic index immediately before exercise
  depending on blood glucose e.g.
• isotonic carbohydrate drink
• plain biscuits/ jaffa cakes
• fruit juice
• Scone, scotch pancakes
• Sweets eg jelly beans, jelly babies

67
Carbohydrate during exercise

• Isotonic drinks
• energy bars
• raisins/bananas
• jaffa cakes
• carbohydrate gel

68
Carbohydrate post exercise

• Essential to replenish depleted glycogen stores
• Rate of glycogen resynthesis is greatest in the
  first 2 hours after exercise
• Complete refuelling may take up to 20 hours
• Encourage CHO intake immediately after exercise

69
Blood glucose can decrease during exercise if

• Hyperinsulinamia exists during exercise
• Exercise is prolonged or intensive
• More than 2 hours has elapsed from last meal
• No additional CHO is consumed before or during
  exercise

70
Blood glucose can increase during exercise if

• Hypoinsulinaemia exists during exercise
• Exercise is very intense or strenuous
• Excessive CHO is eaten before or during exercise

71
Blood glucose remains more stable during exercise
if ...

• Plasma insulin concentration is normal before
  exercise
• Appropriate amount of CHO is consumed before or
  during exercise
• Exercise is short

72
General Exercise Guidelines

• Blood glucose monitoring before and after
  exercise
• Identify when changes in insulin or food intake
  are necessary
• Learn the different glycaemic response to
  different exercise conditions
• Be aware of exercise induced hypoglycaemia

73
Hydration

• Increased fluid intake is necessary to avoid
  dehydration and may improve performance during
  prolonged exercise, especially when sweat loss is
  high.
• These fluids may contain some carbohydrate, the
  concentration of which will be dictated by both
  duration of exercise and climatic conditions
• Lausanne consensus statement 1991

74
Hydration

• Dehydration can affect blood glucose levels and
  heart function adversely
• Exercise can be impaired if you are dehydrated by
  as little as 2
• Fluid loss in excess of 5 can decrease ability
  to train and compete

75
Fluid requirements

• Sedentary individuals require 2-3 litres/day
• Sweat rates during exercise are 0.5-1.5
  litres/hour
• Trained athletes can lose up to 3 litres/hour in
  hot and humid conditions
• Limit dehydration by replacing fluid lost as sweat

76
Fluid requirements

• 1 kg weight loss 1000ml sweat
• Fluid should be taken in all sporting events
  lasting more than 30 mins
• 200ml every 20 mins eg for a marathon

77
Sports drinks

• A non alcoholic beverage using science to make
  claims about enhancing physical performance
  during sporting activity and speeding recovery

78
Classification of sports drinks

• Hypotonic
• Isotonic
• Hypertonic

79
Hypotonic

• 2-3g carbohydrate per 100ml
• Low level electrolytes
• Fluid replacement
• can be taken before, during and after exercise
• Eg Lucozade hydro, Replay

80
Isotonic

• 5-7g Carbohydrate per 100ml
• electrolyte concentration similar to body fluids
• source of fluid and fuel
• can be taken before, during and after exercise
• Eg,Lucozade Sport, Isostar, Gatorade

81
Hypertonic

• Contain gt 10g carbohydrate per 100ml
• high concentration of dissolved substances
• Fuel replacement
• Should only be used after exercise
• Eg Lucozade energy, Ultra fuel

82
Guidelines for fluid intake before exercise

• Drink 400-600ml fluid in the 2 hours before
  exercise
• Sports drinks must be used with caution because
  of the effect on the pre-exercise blood glucose
  level

83
Guidelines for fluid intake during exercise

• Drink sufficient fluid to limit losses as sweat
• If exercise gt 1hour, drink 150-200ml every 15-30
  mins (30-60g CHO /hr)
• Isotonic sports drinks may be useful in providing
  both fluid and carbohydrate during exercise
• Avoid excess fluid intake i.e. weight gain

84
After exercise

• Volume of fluid needed depends on sweat losses
  and ongoing obligatory losses e.g. sweat and
  urine
• Isotonic or hypertonic sports drinks may be
  useful for maintaining post exercise blood
  glucose levels and refuelling glycogen stores

85
Physical activity and Type 2 diabetes

• Most people are insulin resistant
• Hyperinsulinaemia and hyperglycaemia
• Reduction in the number and function of GLUT4
  molecules
• Deficiencies in enzymes eg glycogen synthase
• Risk of hypos limited

86
Prevention of cardiovascular disease

• Risk factors
• Hypertension
• Hyperinsulinaemia
• Central obesity
• Hypertriglyceridaemia/low HDL/raised LDL
• Elevated free fatty acids
• Improvements in these linked to a decrease in
  insulin levels physical activity improves
  insulin sensitivity

87
Physical activity and Type 2 diabetes - prevention

• The DPP and FDP have shown that in people with
  IGT a programme of physical activity combined
  with weight control reduced the risk of
  developing DM by 58
• ADA recommend 150 mins of moderate to vigorous
  physical activity with a modest energy-restricted
  diet (level A)
• ADA Diabetes Care 200629(6)1433-1438

88
Improvement in HbA1c

• Boulé 2001 showed an improvement in HbA1c (7.65
  vs 8.31) independent of weight loss
• Additional benefits can be achieved by increasing
  the intensity of the exercise (Boulé 2003)

89
Effect on risk of cardiovascular and overall
mortality

• Higher levels of aerobic fitness and/or physical
  activity are associated with a lower
  cardiovascular and overall mortality even after
  adjustment for other risk factors
• Higher mortality with higher BMI due to cardio
  respiratory fitness. No difference between weight
  groups when this taken into account

90
Frequency of exercise

• Most clinical trials with people with Type 2
  diabetes have used 3 days/week
• The effect of a single bout of aerobic exercise
  on insulin sensitivity lasts 24-72h
• There should not be more than 2 consecutive days
  without aerobic physical activity
• The effect of resistance training may last longer

91
ADA recommendations

• 150 mins/week of moderate intensity exercise
• (40-60 VO2 max, 50-70 max HR)
• or
• 90 mins/week vigorous exercise
• (gt60 VO2 max, gt70 max HR)
• Activity over 3 days/week. No more than 2
  consecutive days without activity. (Level A)
• ADA Diabetes Care 200629(6)1433-1438

92
Weight loss and weight maintenance

• Exercise alone - approx 2 kg
• obese have difficulty in producing significant
  energy deficit due to a reduction in activity
  outside exercise sessions and increase in food
  intake (Wing 2002)

93
Weight loss and weight maintenance

• Higher volumes of exercise (approx 1 hr/day of
  moderate intensity) can produce as much fat loss
  as equivalent calorie restriction and improved
  insulin sensitivity (Ross 2000)
• Need greater volume of exercise to maintain major
  weight loss compared to that needed to improve
  glycaemia and cardiovascular risk

94
Weight loss and weight maintenance

• People who have successfully maintained a large
  weight loss (gt13.6 kg) performed approx 7
  hours/week of moderate- vigorous aerobic activity
  
• ADA Diabetes Care 200629(6)1433-1438

95
ADA Recommendations

• gt4hr/week of moderate to vigorous aerobic and/or
  resistance exercise to reduce risk of CVD (level
  B)
• 7hr/week of moderate or vigorous exercise for
  long-term maintenance of major weight loss (level
  B)
• ADA Diabetes Care 200629(6)1433-1438

96
Resistance exercise

• In the absence of contraindications people with
  diabetes should be encouraged to perform this 3
  times/week
• 3 sets of 8-10 repetitions at a weight that
  cannot be lifted more than 8-10 times (Level A)
• Safe even in men with significant risk of cardiac
  events (Featherstone 1993)
• ADA Diabetes Care 200629(6)1433-1438

97
Exercise guidelines for Type 2 diabetes

• Avoid vigorous exercise if ketones present
• Probably no need to avoid exercise if blood
  glucose gt 17 mmol
• If person feels well, is adequately hydrated and
  no ketones no need to delay exercise based on
  hyperglycaemia
• ADA Diabetes Care 200629(6)1433-1438

98
Exercise guidelines for Type 2 diabetes

• Blood glucose lt 5.5mmol- extra CHO only if
  patient treated with insulin or insulin
  secretagogue or reduce medication (Level E)
• Supplementary CHO is not usually necessary in
  patients treated with diet, metformin, alpha
  glucosidase inhibitors or thiazolidinediones
• ADA Diabetes Care 200629(6)1433-1438

99
Plan ahead

• Whatever the level of exercise, optimum results
  can only be achieved with careful planning to
  include
• Food
• Frequent blood glucose monitoring
• Insulin management
• Type and intensity of exercise
• Fitness level

100
Teamwork

• Patient/family
• Teacher or coach
• Dietitian
• Diabetes Nurse
• Doctor

101
Go for Gold!

• 5 Olympic Gold medals
• Diabetes is just another part of the equation

102
Web sites

• www.disen.org
• www.uksport.gov.uk
• www.eis2win.co.uk
• www.runsweet.com.uk

103
Thank You !