Exercise in Diabetes/Obesity
July 25, 2008
American Obesity Epidemic
Exercise in Diabetes/Obesity Sheri R. Colberg, PhD, FACSM Associate Professor of Exercise Science Old Dominion University Norfolk, Virginia
Global Obesity Epidemic
Dr. Sheri Colberg
Global Obesity Epidemic
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Exercise in Diabetes/Obesity
July 25, 2008
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Global Diabetes Epidemic 17.7 30.3 71%
3.0 6.7 123%
40.1 104.4 160%
World 2000 = 171 million 2030 = 366 million 114% increase
Wild et al. Diab Care, 27: 1047–53, 2004
Who Is “At Risk”?
20.8 42.3 103% 8.4 21.3 154%
4.6 11.3 146%
Why Worry about Diabetes?
Overweight (BMI>85th percentile) Family history of type 2 diabetes Minorities (African(African-American, Native American, Hispanic/Latino, Pacific Islanders) Over age of 10 (mid to late puberty) Insulin resistant (acanthosis nigricans, nigricans, hypertensive, dyslipidemic, dyslipidemic, PCOS)
1 in 3 people to develop diabetes 50% chance for most minorities Average life span ↓ 12 years QOL ↓ for 20+ yrs
What Causes Diabetes?
Family history of T2 DM Loss of beta cells/less insulin release Poor dietary choices Overweight or obese Insulin resistance Physical inactivity
Am. Diabetes Association, Diab. Care, 23(3): 381-389, 2000
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
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What Decreases Insulin Action?
Genetics Poor diet Excess body fat Visceral (intra(intra-abdominal) fat Physical inactivity Low-level inflammation
Genetics
How big of a role does family history of T2 DM play in children?
54 white, healthy, nonnon-DM children (~12 yrs)
In particular, adolescents with (+) family history had ↓ insulin sensitivity (IS), with impaired glucose disposition index (IS x 1st-phase insulin release) Arslanian S et al. Diab Care, 28(1): 115-119, 2005
Genetic Effect on Insulin Action
Poor Diet
Ad lib ↓ glycemic load diet (GL) vs. energyenergy-restricted, low fat diet (conventional) 14 obese adolescents (ages 13 to 21) 4040-45% CHO with low/moderate GI vs. 5555-60% CHO with any GI 3030-35% fat vs. 2525-30% in “low fat” fat”
Arslanian S et al. Diab Care, 28(1): 115-119, 2005
Dr. Sheri Colberg
Measured weight loss and degree of insulin resistance (IR) after 12 months
Ebbeling CB et al. Arch Pediatr Adolesc Med, 157(8): 773-779, 2003
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Exercise in Diabetes/Obesity
July 25, 2008
Lower Gl & GL ↑ Insulin Action
BMI and Physical Activity
3
C h a n g e o v er 1 2 m o n th s
2
Increase
1
IR
0 -1 -2
Fat Mass (kg)
Decrease Conventional
-3
Low GL
-4
Ebbeling CB et al. Arch Pediatr Adolesc Med, 157(8): 773-779, 2003
Excess Body Fat (Pima Youth)
Thompson DL et al. Med Sci Sports Exerc, 36: 911-914, 2004
Activity in “At Risk” Youth
90 “at risk” Pima Indian children (39M, 51F) studied at 5 and 10 years of age
Bunt JC et al. Diab. Care, 26: 2524-2530, 2003
Dr. Sheri Colberg
Measured IS, adiposity, physical activity, and total energy expenditure
Children with greater ↓ in activity levels (from age 5 to 10) had greater ↓ in IS, independent of changes in weight or adiposity Bunt JC et al. Diab. Care, 26: 2524-2530, 2003
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Exercise in Diabetes/Obesity
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↓ Physical Activity = ↓ IS
Is Weight Loss Essential?
Adj. Δ IS Index (log10)
Hamman RF et al. Diab. Care, 29:2102-2107 , 2006
Bunt JC et al. Diab. Care, 26: 2524-2530, 2003
Is Weight Loss Essential?
Lower fat intake & physical activity predicted wt loss (5(5-7% usual) However, only exercise kept it off Insulin action ↑
In DPP, weight loss was the most important factor to prevent diabetes (↓ (↓ 58%) Every kg (2.2 lbs) lost ↓ risk 16%
Is Weight Loss Essential?
Insulin resistance and T2 DM involve interaction of many genes with physical inactivity, dietary patterns, & weight gain Dietary changes alone improve insulin action without significant weight loss
¾ Physical
inactivity (low VO2max) poses an independently greater risk for insulin resistance than excess body fat
Hamman RF et al. Diab. Care, 29:2102-2107 , 2006
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
July 25, 2008
Aerobic Training ↓ Visceral Fat
Resistance Train ↓ Visceral Fat
Giannopoulou et al. J Clin Endocrinol Metab. 90:1511–1518, 2005
Ibañez et al. Diab. Care, 28:662–668, 2005
Visceral Fat and Insulin Action
Visceral fat may ↓ IS the most All types of exercise training cause loss of visceral fat Dieting alone (w/o exercise) may not
Low-Level Inflammation
Inflammatory markers released by fat/macrophages (cytokines), such as ILIL-6, TNFTNF-alpha, resistin, resistin, etc. Markers’ Markers’ release decreased by: Dietary improvements Loss of visceral fat? Physical activity Salicylates, Salicylates, TZD, statins
Shoelson SE et al. J Clin. Invest., 116:1793-1801, 2006
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
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Can Exercise Prevent Diabetes?
Can Vigorous Ex Prevent DM?
Can vigorous aerobic exercise help prevent onset of type 2 diabetes? Prospective study of 21,271 US male physicians, ages 4040-84, followed 5 yrs SelfSelf-reported “vigorous” vigorous” exercise
Incidence of type 2 DM ↓ as frequency of vigorous exercise ↑ Manson JE et al. JAMA, 268(1): 63-7, 1992
Vigorous Ex ↓ DM Risk in Men Age-Adjusted Relative Risk
1
1
0.77
0.8
0.62
0.6
0.58
0.4
Is moderate aerobic exercise (e.g., walking) enough to prevent onset of type 2 diabetes? Prospective study of 70,102 female nurses ages 4040-65 followed 8 years Survey on leisureleisure-time activities to determine weekly energy expenditure
0.2 0 5
Frequency of Vigorous Exercise (Times per Week)
Manson JE et al. JAMA, 268(1): 63-7, 1992
Dr. Sheri Colberg
Can Walking Prevent Diabetes?
Hu FB et al. JAMA, 282(15): 1433-39, 1999
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Exercise in Diabetes/Obesity
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Moderate Ex ↓ DM Risk in Women 1 0.85 0.79
BMI 25 kg/m2
0.8
0.7
0.67
0.6
0.4
0.2
0.16
0.14
0.11
0.14 0.08
0 1-2.0 (0.8)
2.1-4.6 (3.3)
4.7-10.4 (7.7)
10.5-21.7 (15.7) >21.8 (35.4)
Quintile, MET-Hours per Week (median)
Hu FB et al. JAMA, 282(15): 1433-39, 1999
Diabetes Prevention Program
ThreeThree-year study of 3,234 overweight, individuals with IGT (45% minorities) Intensive lifestyle intervention group ↓ risk of type 2 DM by 58% 30 min of moderate, daily exercise Moderate 55-7% ↓ in body wt (15 lb)
Metformin (by ↑ IS) alone ↓ risk 31%
DPP Research Group, New England J. Med., 346: 393-403, 2002
Dr. Sheri Colberg
MET scores calculated from 8 common physical activities, including walking Greater leisureleisure-time activity (both duration and intensity) associated with lower risk Faster usual walking pace independently associated with lesser risk Same total energy used during walking or vigorous activity results in similar ↓ in risk DPP Research Group, New England J. Med., 346: 393-403, 2002
Lifestyle Most Effective in Older Reduction in DM (%)
Relative Risk of Type 2 DM
1
Moderate Exercise Suffices!
80
Metformin
70
Lifestyle
60
Life vs Met
50 40 30 20 10 0
25-44
45-59
>60
Overall
Age (years)
DPP Research Group, New England J. Med., 346: 393-403, 2002
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Exercise in Diabetes/Obesity
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Effects of Physical Activity
Improving Insulin Action with Physical Activity
A single bout of exercise has long been known to increase insulin sensitivity, at least temporarily Acute exercise results in greater glucose storage in muscle (as glycogen) postpost-ex ExerciseExercise-induced improvements in IS can be partially negated by overfeeding Hagobian & Braun. Metabolism, 55: 402-408, 2006
Improved Glucose Levels
Improved Insulin Action 200
No Exercise
250
No Exercise
225
7 Days Exercise
200 175
*
*
150
*
125
Plasma Insulin (U/ml)
Plasm a G lu co se (m g /d l)
275
150
7 Days Exercise 100
*
50
* *
100
0
0
30
60
90 Time (m in)
120
150
Rogers et al. Diab. Care, 11(8): 613-18, 1988
Dr. Sheri Colberg
180
0
30
60
90
120
150
180
Time (min)
Rogers et al. Diab. Care, 11(8): 613-18, 1988
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Exercise in Diabetes/Obesity
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Exercise ↑ IS More than Dieting
Chronic Physical Activity ↑ IS
Diet
Exercise
Kriska AM et al. Diab Care, 24: 1175-1180, 2001
Training Volume ↑ IS More
Arciero PJ et al. J Appl Physiol, 86: 1930-1935, 1999
“Pick up the Pace” Training
Houmard JA et al. J Appl Physiol, 96: 101-106, 2004
Dr. Sheri Colberg
↑ speed by 10% for 30 minutes per day, 3 days per week Cardiovascular fitness ↑ more with 90 faster min/wk Any type of intervals may be beneficial Johnson S et al. Diab Care, 29(7): 1654-5, 2006
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Exercise in Diabetes/Obesity
Exercise Energy Systems 100
C o n t r ib u tio n o f S y s te m ( % )
Blood Glucose Responses to Exercise
July 25, 2008
80
ATP-CP Glycolysis
60
Aerobic
40
20
0 10 sec
Exercise Fuel Use
30 sec
1 min Time
3 min
5 min
Glucose Uptake in Muscle
Carbohydrate is still the fuel of choice: muscle glycogen (~80%), blood glucose (~20% unless ↑ by hyperglycemia) Little insulin needed for carbohydrate use during exercise Glucose uptake occurs via a contractioncontraction-induced mechanism separately, but additively with insulin
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
July 25, 2008
Glycemic Responses to Exercise
200
400
DM lacking Insulin
Blood Glucose (mg/dl)
B lo o d G lu c o s e (m g /d l)
Maximal Exercise Effects
350 300 250
DM with Insulin
200 150 100
180 160 140
Type 2 DM
120
Control
100
Nondiabetic Controls
50
80
0
0
10
20
30
0 5 10 20 Exercise
30
60
120
180
Time (m in)
Time (min) Kjaer M et al. J. Appl. Physiol., 68(5): 2067-74, 1990
Wahren et al. Diabetologia, 14: 213-22, 1978
Timing of Exercise Exercise Recommendations
10.0 PRE 9.5
POST NO EX
9.0
Plasma Glucose (mmol/L)
8.5 8.0 7.5 7.0
*
6.5 6.0 5.5 Meal
Ex Pre
5.0 0
30
Ex Post 60
90
120
150
180
210
240
Time (minutes)
Colberg S et al. J Diab Complic, 2008 (In press)
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
Given that…
Regular physical activity of any type ↑ overall insulin action in most individuals Exercise has a more positive effect on insulin action than dietary changes, genetics, or fat loss Physical activity is essential to prevent type 2 diabetes with aging and long and live well with any type of diabetes
July 25, 2008
Try to Get Your Patients to:
Exercise Plan for Better Health
It’ It’s never too late to start, but patients may need a checkup before, or at least a check of their heart rate & BP Different activities done on a rotating basis at least 30 minutes daily (20 minutes if more vigorous) Endurance, Resistance, and Flexibility ↑ SPA (Spontaneous Physical Activity)
Dr. Sheri Colberg
Be regularly physically active to keep their insulin action enhanced Exercise more vigorously (at least on occasion) to ↑ muscle glycogen use Do some “Pick Up the Pace” Pace” training Exercise longer at the same intensity to ↑ insulin action for a greater time Include both aerobic and resistance workouts to maximize muscle gains
Endurance Activities
Walking at any speed (w/ good socks/shoes) “Cardio” Cardio” machines NonNon-weightweight-bearing (lower extremity joint pain or neuropathy): stationary cycling, aquatic/pool or chair exercises, upper body
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Exercise in Diabetes/Obesity
July 25, 2008
Resistance Activities
Include exercises that work upper and lower body muscles, as well as “core” core” For upper body, minimally do double arm raises, biceps curl, triceps extension Can be done sitting or standing For legs, do knee and hip flexion & extension, calf raises, and side leg raises Abdominal crunches, low back i
Exercise in the Overweight
Excess fat weight may hinder movement Focus on activities that cater to inherent strengths (e.g., height, leg strength) DeDe-emphasize activities such as running and jumping hard on lower extremities WaterWater-based activities may lessen selfselfconsciousness, exercise aversion Initial fitness levels may be very low
Chair Push-Ups Exercise
Sit-to-Stand Exercise
Morley J, Colberg S. The Science of Staying Young, 2007
Morley J, Colberg S. The Science of Staying Young, 2007
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
Core Exercises
July 25, 2008
Flexibility Training
Stretches best done at least 22-3 days per week or after any exercise session Include all major muscle groups Hold stretches for 1010-30 seconds
Colberg S. The 7 Step Diabetes Fitness Plan, 2006
Add in More SPA
It’s Good to Be Regularly Active!
More spontaneous physical activity Leisure activities Adding in little bits of exercise during the day easier for many Fitness gains less Health benefits
Dr. Sheri Colberg
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Exercise in Diabetes/Obesity
July 25, 2008
Exercise Resources
Fitness Info for DM and PreDM The 7 Step Diabetes Fitness Plan Marlowe © 2006 Training tips, strength & flexibility illustrations, and much more
Living Long/Well with Diabetes
Aging Successfully Book The Science of Staying Young McGraw-Hill © 2007
Bob & Gerald Cleveland (157+ yrs of DM)
Marlowe © 2007
Dr. Sheri Colberg
All you need to know to live a long and healthy life (with or without diabetes)
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Exercise in Diabetes/Obesity
July 25, 2008
Guide for Diabetic Exercisers The Diabetic Athlete’s Handbook
Thank You!
Human Kinetics © November 2008 Management of exercisers with type 1 and 2 diabetes
Dr. Sheri Colberg
For more information, visit www.SheriColberg.com
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