Over the next few weeks we will be posting content created in class by our level one MSc (pre-reg) students. This first post looks at how physical activity can help those with type 2 diabetes and was produced by Group A.
What is the scope of the problem for this patient?
Diabetes is becoming more prevalent all around the world, America being the most at risk country. Studies have shown that the lifetime risk in 2000 of developing diabetes is one in three in America, as well as being the 6th leading cause of death (Colberg et al., 2010). Of those ending in death, 65% are related to heart disease and stroke (National Health Interview Survey, 2000). The scope of the problem has become so severe that the prevalence is even increasing in children and young adolescents due to sedentary behaviour (American Diabetes Association, 2000). It is essential that this cycle is reversed in order to avoid difficulties in society. It has been shown that one major risk factor in diabetes in children is family history (close family) as it ranges from 74 – 100%. This may be due to a westernized lifestyle however there is a lack of research on this topic with regards to children.
It has been discovered that the cost of healthcare for those suffering with diabetes is four times greater than those without the disease (Harris, 1998). The main costs come from the complications of the disease ie amputation, blindness, kidney failure and stroke (Cost of Diabetes Report, 2014) With an increase in this epidemic, the strain on the NHS especially will increase.
The best course of action is a multidisciplinary lifestyle intervention targeting exercise, therapeutic education, nutrition and physiological counselling (De FeoF et al, 2013).
The Evidence for Physical Activity, in a Diabetes Population
Lifestyle interventions appear to be at least as effective as pharmacological interventions. However, exercise is associated with fewer side effects, and it also has a positive influence on cardiovascular events, quality of life, and mortality. One key issue is the need for compliance for exercise interventions as the effects of are not permanent, and therefore exercise needs to be reinforced on a regular basis. The more overweight someone is, the greater impact lifestyle interventions will have (Gillies et al., 2007).
Just 15 days of aerobic exercise is enough to have an impact on insulin sensitivity (Madden, K.M. (2013) ‘Evidence for the benefit of exercise therapy in patients with type 2 diabetes’, Diabetes Metab Syndr Obes, 6.)
150 mins per week of PA along with diet changes reduced the risk of progression from impaired glucose tolerance to T2 diabetes by 58% (Sigal, R.J., Kenny, G.P., Wasserman, D.H., Castaneda-Sceppa, C. and White, R.D. (2006) ‘Physical activity/exercise and type 2 diabetes’, Reviews/Commentaries/ADA Statements, 29(6), pp. 1433–1438. doi: 10.2337/dc06-9910)
Substantial reductions in mortality for both men and women and in both T1 and T2 diabetes. Reductions overall mortality of 39-70% over 15 to 20 years. (Sigal, R.J., Armstrong, M.J., Colby, P., Kenny, G.P., Plotnikoff, R.C., Reichert, S.M. and Riddell, M.C. (2013) ‘Physical activity and diabetes’, Canadian Journal of Diabetes, 37, pp. 40–44. doi: 10.1016/j.jcjd.2013.01.018.)
Increased exercise aids in the effectiveness of pharmacological treatment by increasing the cardiovascular function and nutrient absorption.
Risk reductions are observed in as little as 30 minutes of moderate intensity exercise a day.
ACSM and ADA 2010
Increase in quality of studies establishing importance of fitness and exercise.
Physical Activity in prevention and management.
Regular Physical Activity increases blood glucose and prevent/delay type 2 diabetes.
Physical Activity and modest weight loss decreases risk of type 2 diabetes by 58% in high risk populations.
Acute and chronic improvements in insulin action for both aerobic and resistance training.
Policies for Type 2 Diabetes
Global Guideline for Type 2 Diabetes Diagnosis/Screen
Each programme should decide whether to have a programme with undiagnosed diabetes. This decision should be based on prevalence and resources available.
Detection programmes should be based on:
- Identifying high risk individuals with questionnaire
- glycemic measure in high risk individuals
Diabetes can be diagnosed based on WHO criteria (numbers not disclosed)
People that are screened and diabetes detected should be given treatment and care.
Offer care to all people with diabetes, taking into account cultural wishes and desires.
Encourage a collaborative relationship by involving diabetes person in consultation. Ensure issues important to person are addressed.
Agree on a care plan, review it annually or more often, modify according to change in wishes
Use protocol-driven care to deliver care plan
Ensure each person with diabetes is recorder on list of people, to facilitate recall for annual surveillance.
Provide telephone contact between clinic visits.
Provide urgent access to diabetes health care advice for unforeseen consequences.
Use data gathered in routine care to support quality assurance and development activities.
International Guidelines Exercise Recommendation
Aerobic: either 150 minute minimum moderate intensity, 50-70% max HR/can continue conversation, 3 days week no more than 2 consc. days, brisk walk would be appropriate. Or 90 mins minimum vigorous if no CV C.I., 77-95% max HR progression/ca’t continue convo, brisk jogging recommended.
Resistance: in addition to aerobic recommended, min 2x week non-consec days, 1-4 sets 5-10 reps of mulit-joint, initially 50-69RM progressing to 70-84RM.
Combined aerobic + resistance had favourable impact of glyceamic control.
National strategy and policy to prevent type 2 Diabetes – NICE Guidelines/Pathways
- Creating an integrated strategy for non-communicable diseases linked to diet, physical activity and being overweight or obese
- Conveying healthier lifestyle messages to the whole population
- Make sure these messages are clear and consistent
- Make sure they address misconceptions about diabetes (e.g. fatalism, what actually is a healthy weight, stigma surrounding disease)
- Make sure national media conveys correct and culturally appropriate information (given different target audiences)
- Don’t reinvent the wheel – use existing materials, including those from other countries, when appropriate
- Emphasize need to spend less time being sedentary, importance of being physically active and maintaining a healthy weight, increase awareness of healthier food choices.
- Working with caterers, food manufacturers, food retailers and others to encourage people to eat more healthily – and monitoring and assessing the population’s diet
- Make better quality food more available
- Work to reduce the saturated fat and salt content, as well as the total amount of calories in the foods available.
- Encourage the use of healthier cooking methods
- Work to change pricing strategies to make healthier choices more affordable
- Work to provide clear nutritional information on food
- Encouraging people to be more physically active and monitoring and assessing physical activity levels
- Improve knowledge of the national physical activity guidelines – make sure people know how active they are meant to be
- Encourage even small changes towards being more active
- Monitor the population’s physical activity levels to determine the success of the interventions
- Management Advice
- Key recommendations
- Evidence based education interventions around time of diagnosis with annual reinforcement and review
- Dietary advice should be provided to all newly diagnosed people and reviewed annually with healthy balanced eating of high fibre, low glycaemic index sources of carbs and oily fish, control of intake containing free sugars and saturated and trans fatty acids
- Self-monitoring of plasma glucose levels is only beneficial for a self-management education where education to understand the results should be provided
- Assess cardiovascular risk every year including full lipid profile
- Check annually about development of neuropathic symptoms
Physiological Effects of Exercises on Type 2 Diabetes
Meta-analysis on different modes of exercise on type 2 diabetes by Snowling and Hopkins, 2006 (N=1003 using 27 studies)
- Clear and small reductions in A1C (blood glucose test) were seen
- This was done using a small to moderate intensity of exercise (aerobic only)
- However, the use of combined exercise (aerobic & resistance) highlighted a large effect on insulin sensitivity.
- Therefore the study concluded that aerobic, resistance and combined exercise had small to moderate benefits on glucose control in type 2 diabetic patients and small beneficial effects on some related risk factors for complications of diabetes. Furthermore, there is some evidence of small additional benefits resulting from combining aerobic and resistance exercise.
- Structured exercise programs had a statistically and clinically significant beneficial effect on glycemic control (not primarily mediated by weight loss)? (Sigal et al., 2006)
- Improves glycaemic control (Yang et al., 2014) → decreased glycated hemoglobin levels of 0.6% (Thomas et al., 2006).
- No study reported adverse effects in the exercise group or diabetic complications (Thomas et al., 2006)
- Improves blood lipid profiles (Yang et al., 2014)
- Increased insulin response and decreased plasma triglycerides (-0.25mmol/L)
- Effects of various types of exercise:
- Aerobic exercise is the most extensively studied (Yang et al., 2014)
- Decrease glycosylated hemoglobin of 0.46% (5.03 mmol/mol) in aerobic
- Decrease glycosylated hemoglobin of 0.32% (3.50 mmol/mol) in resistance training
- No evidence that resistance training differs from aerobic exercise in impact on cardiovascular risk markers or safety (Yang e al., 2014)
A study that compared the effects of 12 week progressive combined exercise (3min/week) on 18 diabetic subjects and 20 controls of similar age, bmi and aerobic capacity found that mitochondrial function was restored to control levels, insulin sensitivity was significantly improved and metabolic flexibility was restored to control levels in type 2 diabetes individuals ( Meex et al 2010).
A combination of aerobic training and resistance training has benefits on the oxidative capacity of muscle. This improves skeletal muscle glucose disposal, reduces hepatic glucose production thereby improving glucose tolerance, insulin sensitivity and glycemic control.
Further benefits include an improvements in cognitive functioning. ( Cooper et al., 2011)
A study comparing groups being treated with medication (metaformin) versus those being treated with intensive exercise and nutrition counselling, demonstrated that the exercise group had a 58% reduction in the progression of T2DM after 2.8 year follow up.
Those who exercise regularly can reduce the dosage and even the need for insulin and oral agents while decreasing LDL cholesterol, triglycerides, and blood pressure in association with increasing HDL.
Studies, and meta analysis based on these studies, have shown that exercise has beneficial physiological effects for people with Type 2 Diabetes Mellitus (T2DM). These include; body weight (adipose tissue ratio) reduction, blood glucose levels, insulin activation and resistance, rates of fat oxidation, blood cholesterol levels, and blood pressure (O’Hagan, De Vito, & Boreham, 2013). Although there are the typical limitations for studies including differentiation in participant group size, drop out rates, different measurement tools, and the fact that most of the participants have their symptoms under control; several meta analyses have manage to quantify these findings as statistically significant (O’Hagan, De Vito, & Boreham, 2013). These are exercise benefits for everyone however they are greater for people with T2DM because they have a greater risk to begin with (O’Hagan, De Vito, & Boreham, 2013).
- Lack of time
- Younger patient more likely to report
- Physical discomfort (34%)
- Reports from older, with higher BMI
- Access to facilities
- Lack of motivation
- Embarrassment of body image
- Females and unmarried individuals more likely to report
- Diabetes specific management
- Blood sugar management during exercise
- No knowledge about why exercising is good to reduce blood sugar
- Lack of social support
- Past negative experiences, boredom, dislike of gym
(Dave et al 2015, Egan et al 2013, Lascar et al 2014)
Bassuk, S.S. and Manson, J.E., 2005. Epidemiological evidence for the role of physical activity in reducing risk of type 2 diabetes and cardiovascular disease. Journal of applied physiology, 99(3), pp.1193-1204.
Colberg, S.R., Sigal, R.J, Fernhall, B., Regensteiner, J. G., Blissmer, B.J, Rubin, R.R., Chasan-Taber, L., Albright, A.L. & Braun, B. (2010), ‘Excersise in Type II Diabetes”, Diabetes Care, 33(12), pp147-167
Dave, D., Soni, S. & Irani, A. 2015, “Identification of barriers for adherence to exercise in type 2 diabetes mellitus—a cross sectional observational study”, Physiotherapy, 101, pp. e297
De Feo et al. 2013. Diabetes and Exercise. 2nd ed. Endocrinology of Physical Activity. Springer Science and Business: New York
Egan, A.M., Mahmood, W.A.W., Fenton, R., Redziniak, N., Tun, T.K., Sreenan, S. and McDermott, J.H., 2013. Barriers to exercise in obese patients with type 2 diabetes. QJM, 106(7), pp.635-638
Gillies, C. L., Abrams, K. R., Lambert, P. C., Cooper, N. J., Sutton, A. J., Hsu, R. T., & Khunti, K. (2007). Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: A systematic review and meta-analysis. The British Medical Journal, 334. doi: http://dx.doi.org/10.1136/bmj.39063.689375.55
Harris, M.I. (1998), “Diabetes in America: Epidemiology and Scope of the Problem”, Diabetes Care, Vol. 21, pp. 11-15
Home, P., Mant, J., Diaz, J. and Turner, C., 2008. Management of type 2 diabetes: summary of updated NICE guidance. Bmj, 336(7656), pp.1306-1308.
Lascar, N., Kennedy, A., Hancock, B., Jenkins, D., Andrews, R. C., Greenfield, S. And Narendran, P. 2014. Attitudes and Barriers to Exercise in Adults with Type 1 Diabetes (T1DM) and How Best to Address Them: A Qualitative Study. Public Library of Science. 9 (9), pp. 1-8.
NICE Guidelines 2016 – National strategy and policy to prevent type 2 diabetes. https://pathways.nice.org.uk/pathways/preventing-type-2-diabetes/national-strategy-and-policy-to-prevent-type-2-diabetes
O’Hagan, C., De Vito, G., and Boreham, C.A.G., 2013. Exercise Prescription in the Treatment of Type 2 Diabetes. Current Practices, Existing Guidelines and Future Directions. Sports Medicine. 43. Pp. 39-49.
Sibal, L. and Home, P.D., 2009. Management of type 2 diabetes: NICE guidelines. Clinical medicine, 9(4), pp.353-357.
Sigal, R.J., Kenny, G.P., Wasserman, D.H. & Castaneda-Sceppa, C. 2004, “Physical activity/exercise and type 2 diabetes”, Diabetes care, vol. 27, no. 10, pp. 2518-2539.
Type II Diabetes in Children and Adolescents, Paediatrics, March 2000, 105(3)
Contributors: Greg Barnes, Alexander Benin, Ryan Bennett, Jessica Marie Buffam, Natalja Chorosajeva, Blair Colvin, Hugo David Curley, Claire Davidson, Jason Freeman, Paul Griffin, David Monkman Hickey, Jackson Wyatt Hill, Caroline Elizabeth Johnston,Melissa Megan-Marie Leffelhoc, Orlaith Munnelly, Blaise Joseph Peters, Mitchell Eugene Petten, Aiste Pranciliauskaite, Claire Rankin, Heather Sabin Sauverwald, Frances Ann Young, Laura Anne Williamson, Chelsea Chrystal Windl.
Class Tutor: David Hegarty