Transcript Stress Testing Pre Exercise

First 15 Minutes Exercise a day
 416,175 people – average follow 8years
 3 years increase in Life expectancy
 15mins/day - 14% reduction all cause mortality
 Every extra 15 mins/day 4% extra < Mortality
 Chi Pang Wan et al Lancet Vol. 378-9798 1244-1253 Aug 2011
Exercise in non-diabetics
 Decreases insulin release
 Stimulates glucose transport into muscle
 Therefore, increase in insulin sensitivity
2
Exercise in non-diabetics
 Increases cortisol, catecholamines
 Increases glucagon
 Free fatty acids and liver glycogen to be mobilized for
energy
3
Fitness and Incident Metabolic Syndrome;
9007 Men and 1491 Women
Age-Adjusted Rate/1000
45
40
p<0.001,each
35
Middle
30
High
Low
25
20
15
10
5
0
Men
Women
LaMonte M et al. Circulation. 2005; 112:505-512
Fitness and Metabolic Syndrome;
11,833 Patients with 3-Day Diet Records
Odds of Metabolic Syndrome*
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Thirds of CRF
Low
Moderate
High
Low intake
*Adjusted for confounders, including
macronutrient intake
High intake
Finley CE et al. JADA 2006; 106:673
Fitness and Incident Type 2 Diabetes;
8633 Healthy U.S. Men
Diabetes incidence/1000 men
6
5
4
3
2
1
0
Low
Mod
Cardiorespiratory Fitness
High
Wei M et al. Ann Int Med 1999
Fitness and Incident Type 2 Diabetes;
4747 Japanese Men;
Tokyo Gas Company
Relative risk adjusted for age and risk factors
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
I
II
III
IV
Level of Fitness
Sawada SS et al. Diab Care 2003; 26:2918
All-Cause Mortality by Fitness Groups
in 3,757 Men with Metabolic Syndrome
Odds Ratio
3
2.5
p for trend <0.001
2
1.5
1
0.5
0
Low
Moderate
High
Cardiorespiratory Fitness Groups
Katzmarzyk et al. Arch Int Med 2004; 164:1092
Risk of cardiovascular disease mortality by cardiorespiratory fitness and body mass index
categories, 2316 men with type 2 diabetes at baseline, 179 deaths.
Blair S N Br J Sports Med 2009;43:1-2
©2009 by BMJ Publishing Group Ltd and British Association of Sport and Exercise Medicine
Fitness and Cancer;
Mortality in 1744 Men with Diabetes
Relative risk of
Cancer Death *
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
p for trend =0.002
Low
Moderate
High
Cardiorespiratory
Fitness
*Adjusted for age and risk factors
Thompson AL et al. In progress
Exercise and Colon Cancer
• Important in both primary and secondary
prevention
• Median risk reduction:
– 30-40% in men
– 10-20% in women
– Dose-related response; Need 30 min, 5 days
per week
• Cancer survivors:
– Improved quality of life
– Less severe side effects from chemo
– Appear to have reduced mortality rate
Cardiovascular Health Study;
Elderly Individuals with CAD
Physical Activity and Mortality
• 1045 women and men ≥65 years with
coronary artery disease
• Followed for mortality for 9 years
– 489 deaths in 7284 patient years of follow-up
• Physical activity assessed at baseline and
at 3 years of follow-up
• Shows dose-response relationship PA and
mortality in patients with CAD
Janssen I & Jolliffe CJ. MSSE 2006; 38:418
Physical Activity and Dementia in
Women and Men; ≥65 Years (6yr f/u)
Age- and sex-adjusted Hazard
ratio for incident dementia
1
Age-specific incidence of
dementia/1000 person-years
60
0.9
50
0.8
0.7
40
0.6
0.5
30
0.4
20
0.3
0.2
10
0.1
0
0
<3/week
3+/week
Exercise Habits
Exercise and incident dementia
In 1740 women and men
Larsen EB et al. Ann Int Med 2006; 144:73-81
<=10 SPPB 11+ SPPB
Short physical performance
battery scores Vs dementia incidence
in 2288 women and men
Wang L et al. Arch Int Med 2006; 166:1115
Computer and Physical Activity and
Mild Cognitive Impairement
 No exercise and no computer use
 Exercise but no computer use
 Computer use but no exercise
 Both exercise and computer use
1.00
0.68
0.58
0.36
Lifestyle-related Risk Factors and Risk of
Future Nursing Home Admissions; 6462 Adults
RiskFactor
45-64years
HazardRatio(95%CI)
Smoking
1.56(1.23-1.99)
Inactivity
1.40(1.05-1.87)
BMI≥30.0
1.35(0.96-1.89)
HighBP
1.35(1.06-1.73)
HighCholesterol
1.14(0.89-1.44)
Diabetes
3.25(2.04-5.19)
Valiyeva E et al. Arch Int Med 2006; 166:985
Indications for Exercise
 Longevity
 Quality of Life
 Socialization
 Weight control
 Disease prevention
 Disease management
 ….(I could go on)
Men
Women
No Physical Exercise During a 7-Day Period
40
37
33
Percent
30
27
20
26 27
21
21 21
18 17
10
0
14
11
1988
2002
18-34
1988
2002
35-54
1988
2002
55+
Slan Survey 1999
% reporting moderate &/or strenous
exercise 3 or more times per week for
at least 20 mins
41
41
40
40
39
38
38
37
36
1998
2002
2007
Percentage of respondents who reported no
exercise in an average week
Trend
towards inactivity being reversed?
Slan survey results reporting no
exercise
30
25
28
23
19
20
% reporting no
exercise
15
10
5
0
1998
2002
2007
Percentage of respondents who reported no exercise in an
average week, by age, gender and year
(1998, 2002 and
2007)
‘Get Ireland Active’
www.getirelandactive.ie
Free, individual & confidential support
for older adults to get more physically
active
National Physical Activity Guidelines
Ireland (Adults)
for
 At least 30 minutes of moderate intensity physical
activity on 5 days a week
 30 mins can be accumulated over the day but you
must be active for at least 10 mins each time to make
it count
 Also one min of vigorous activity counts as two mins of
moderate activity, i.e. 15 mins of vigorous activity
equals 30 mins of moderate activity needed each day
 Same for older adults
 Adults with disabilities - be as active as your ability
allows, aim to meet adult guidelines
National Physical Activity Guidelines
Ireland (Adults)
for
 It should be noted that to lose weight 60 – 75 mins of
moderate intensity activity a day may be required
 If you have lost a significant amount of weight, to
maintain weight loss, 60 - 90 mins of moderate
physical activity a day necessary to prevent weight
gain.
 45-60 mins (IASO 2004), 60-90 mins per day (ACSM &
AHA 2008)
 A combination of diet and exercise appears to be the
optimal strategy both for reducing weight and for
maintaining weight loss.
Motivational Interviewing
 OARS
 Open
 Affirmations
 Reflective Listening
 Summarises
The Exercise Prescription
“Think FITT”
• F = Frequency:
– Most days of the week; 5 or more.
• I = Intensity:
– Moderate; 50-70% of max HR or use “sing-talk”
test.
• T = Type:
– Use large muscle groups; something patients like.
• T = Time:
– 30 minutes.
Guidelines for children and young people
(aged 2-18)
 children should be active, at a moderate to vigorous level,
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for at least 60 minutes everyday
include muscle-strengthening, flexibility and bonestrengthening exercises 3 times a week.
moderate to vigorous activity includes everything from
sport, PE, formal exercise & active play
includes everyday activities such as walking and cycling
moderate activity - increased breathing & heart rate, still
able to carry on a conversation, warm or sweating slightly,
comfortable pace
vigorous activity - breathing heavily, cannot keep a
conversation going, faster heart rate & sweating a lot
Barrier
Lack of time
Lack of
knowledge/training in
PA counselling
Lack of success with
changing patient
behaviour
PA counselling not a
priority/not relevant
Number of studies
14
References
10–14, 16–24
8
10, 12, 13, 16–19, 23
8
13, 14, 16–18, 21, 23, 24
7
10,11,14,16,17,23,24
Lack of financial
incentive/reimburseme 5
nt for counselling
10,14,18,20,21
Lack of counselling
protocols
10,12,15,20,21
5
Lifestyle Intervention:
Physical Activity Results
 74% of volunteers assigned to
intensive lifestyle achieved the
study goal of > 150 minutes of
activity per week at 24 weeks
The DPP Research Group, NEJM 346:393-403, 2002
Percent developing
diabetes
Incidence
of Diabetes
Placebo (n=1082)All
Metformin (n=1073, p<0.001 vs. Placebo)
Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )
Lifestyle
(n=1079,
,
Metformin
(n=1073,p<0.001
p<0.001vs.
vs. Metformin
Plac)
Placebo (n=1082) p<0.001 vs. Placebo)
Cumulative incidence (%)
40
30
participants
Risk reduction
31% by metformin
58% by lifestyle
20
10
0
0
1
2
Years from randomization
The DPP Research Group, NEJM 346:393-403, 2002
3
4
Intervention goals
 5% reduction in initial weight
 Exercise ≥30 min/day
 Decrease fat to <30% of caloric
intake
 Increase fibre to ≥15 g per 1000
kcal
 Decrease saturated fat to <10%
of caloric intake
Cumulative probability of
remaining free of diabetes
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
Intervention group
Control group
0
1
2 3 4 5
Study year
6
Tuomilehto et al. N Engl J Med 2001; 344: 1343–50
Cumulative probability of
remaining free of diabetes
1Year intensive intervention
1.2
1.1
4 years
58%
1.0
7 years
43%
0.9
0.8
13years
38%
0.7
0.6
5 Years Delay in onset DM
0.5
0.4
0
SLtDddddddddddudy year
Intervention group
Control group
2
3
4
5
6
1
13year follow up Jan 2013
Weight Change (kg)
Mean Weight Change
0
Placebo
-2
Metformin
-4
Lifestyle
-6
-8
0
1
2
Years from Randomization
The DPP Research Group, NEJM 346:393-403, 2002
3
4
Muscular Strengthening
 Exercise large muscle groups
 8-12 reps; should fatigue by last rep
 Rest 2-3 minutes between exercises
 1 set good, 2 sets better
 Rest day in between
Resistance training prevention
diabetes
 32002 men – 18 years
 150 minutes/week
 Resistance Training alone
 Aerobic Training alone
 Both
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
Health Professional follow up study
Arch Intern Med. 2012;172(17):1306-1312. doi:10.1001/archinternmed.2012.3138
34% reduction
52% reduction
59% reduction
Combined Training HbA1 DMtype2
Combined Training DM
 The prevalence of increases in hypoglycemic medications
were 39% in the control, 32% in the resistance training,
22% in the aerobic, and 18% in the combination training
groups with the Mantel-Haenszel test for linear association
being significant (P = .005). The prevalence of decreases in
hypoglycemic medications were 15% in the control, 22% in
the resistance training, 19% in the aerobic, and 26% in the
combination training groups (P = .20). The prevalence of
individuals who achieved the composite outcome of either
decreasing hypoglycemic medication or reducing HbA1c by
0.5% without increasing medications were 22% in the
control group, 26% in the resistance training, 29% in the
aerobic, and 41% in the combination training group
Conducting exercise stress testing before
walking is unnecessary. No evidence suggests
that it is routinely necessary as a CVD
diagnostic tool, and requiring it may create
barriers to participation.
ADA/ACSM November 2011
Pre-exercise evaluation
 Cardiac screening is controversial
 Decreased risk in DM of unexpected cardiac death
who exercise
 79% of perfusion abnormalities resolved 3 yrs with
medical therapy
 If exercise treadmill +, poor prognosis
 Don’t know result of interventions
Clin Sports Med 2009;28:379-92
Diabetes Care 2007;30:2892-8
40
Pre-exercise evaluation
 Asymptomatic Type II with + adenosine stress
compared with non screened
 No reduction in cardiac events
 High risk Type II revascularization vs aggressive
medical therapy
 No difference in long term mortality
JAMA 2009;301:1547-55
NEJM 2009;360:2503-15
41
Stress Testing Vigorous
 For exercise more vigorous than brisk walking or
exceeding the demands of everyday living, sedentary
and older diabetic individuals will likely benefit from
being assessed for conditions that might be associated
with risk of CVD, contraindicate certain activities, or
predispose to injuries, including severe peripheral
neuropathy, severe autonomic neuropathy, and
preproliferative or proliferative retinopathy
Who
to
do
stress
test?
 Low to moderate intensity, good control, not many
risk factors
 Start program
 Out of shape, starting program
 Start low to moderate intensity
 OR non-exercise imaging
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92
43
Who to do stress test?
 If moderate to high intensity exercise
 AND/OR ADA guideline risk factors
 Autonomic neuropathy
 PVD, retinopathy
 + EKG
 Stress test
 OR modify risk factors prior to exercise
Handbook of Exercise in Diabetes 2002
Clin Sports Med 2009;28:379-92
44
FACTORS WHICH PREVENT
EXERCISE
 READYNESS TO CHANGE
 Health concerns
 Family commitments
 Work commitments
 Transport difficulties
 Weather
 Cost
 Security concerns
Exercise Type II
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Exercise reverses deficits in metabolism
Basal insulin
HbA1c
Basal glucose
Liver glucose production
Insulin stimulated glucose uptake
GLUT4 receptors
Insulin sensitivity
 Cholesterol, triglycerides
GSSI #90 2003;16(3)
46
Exercise Benefits
 20-30% reduction in HbA1c in Type II
 Decrease lipids
 Decrease blood pressure
 Weight loss and maintenance
 Reduce metabolic syndrome
 Reduce risk of CAD !!
47
Physical Activity and Mortality DM
 Total PA was associated with lower risk of CVD and total
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mortality.
Compared with physically inactive persons, the lowest
mortality risk was observed in moderately active persons:
Hazard ratios were 0.62 (95% CI, 0.49-0.78) for total
mortality and 0.51 (95% CI, 0.32-0.81) for CVD mortality.
Leisure-time PA was associated with lower total mortality
risk, and walking was associated with lower CVD mortality
risk.
In the meta-analysis, the pooled random-effects hazard
ratio from 5 studies for high vs low total PA and all-cause
mortality was 0.60 (95% CI, 0.49-0.73).
Annals of Internal Medicine Online first August 2012
Borg perceived exertion scale

6 No exertion at all
7 Extremely light
8
9 Very light - (easy walking slowly at a comfortable pace)
10
11 Light
12
13 Somewhat hard (It is quite an effort; you feel tired but can continue)
14
15 Hard (heavy)
16
17 Very hard (very strenuous, and you are very fatigued)
18
19 Extremely hard (You can not continue for long at this pace)
20 Maximal exertion
Borg perceived exertion scale
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Perceived Exertion Scale
Level 1: I'm watching TV and eating bon bons
Level 2: I'm comfortable and could maintain this pace all day long
Level 3: I'm still comfortable, but am breathing a bit harder
Level 4: I'm sweating a little, but feel good and can carry on a
conversation effortlessly
Level 5: I'm just above comfortable, am sweating more and can still talk
easily
Level 6: I can still talk, but am slightly breathless
Level 7: I can still talk, but I don't really want to. I'm sweating like a pig
Level 8: I can grunt in response to your questions and can only keep
this pace for a short time period
Level 9: I am probably going to die
Level 10: I am dead
METs
3.5-4
Moderate
Walking at a brisk pace (1 mi every 20 min)
Weight lifting, water aerobics
Golf, not carrying clubs
Leisurely canoeing or kayaking
Walking at a very brisk pace (1 mi every 17 to 18 min)
Climbing stairs
Dancing (moderately fast)
Bicycling <10 mph, leisurely
METs
4.5-6
 Moderately Vigorous Plus
 Slow swimming
 Golf, carrying clubs
 Walking at a very brisk pace (one mi every 15 min)
 Most doubles tennis
 Dancing (more rapid)
 Some exercise apparatuses
 Slow jogging (one mi every 13 to 14 min)
Vigorous Exercise
Hiking
Rowing, canoeing, kayaking vigorously
Dancing (vigorous)
Some exercise apparatuses
Bicycling 10 to 16 mph
Swimming laps moderately fast to fast
Aerobic calisthenics
Singles tennis, squash, racquetball
Jogging (1 mile every 12 min)
Skiing downhill or cross country
Why Resistance Training?
 Improves metabolism – proven reduction in Insulin
Resistance, incidence of D.M., additive effect to
aerobic exercise in prevention and treatment of IHD
 Improves muscle strength – less falls/#s
 Reduced Osteoporosis 1year increase BMD 1.3%
Controls loss 1.2%
 Arthritis – Reduced pain Improved function
Exercise that uses muscular strength to
move a weight or move against a resistive
load
In diabetes resistance exercise of the major
muscle groups on 2 non consecutive days in
the week is recommended
Resistance Training
 Resistance can be own body weight
 Press Up / Sit Up
 Light Weights – Dumb Bells
 Resistance bands
Progression
 Over time and as the person achieves 3 sets of 10-15
reps the weight can be increased, as this produces
impoved blood glucose effects
 As the weight increases the number of reps per set can
be reduced to 8-10
7 Investments that
work for physical activity
1. Whole-of-school’ programs
2. Transport policies and
systems that prioritise
walking, cycling and public
transport
3. Urban design regulations and
infrastructure that provides
for equitable and safe access
for recreational physical
activity, and recreational and
transport-related walking
and cycling across the life
course
4. Physical activity and NCD
prevention integrated into
primary health care systems
5. Public education, including mass
media to raise awareness and
change social norms on physical
activity
6. Community-wide programs
involving multiple settings and
sectors & that mobilize and
integrate community engagement
and resources
7. Sports systems and programs that
promote ‘sport for all’ and
encourage participation across
the life span