Diabetes

Question 1

Definition of diabetes

Answer 1

WHO expert commitee on DM 1980
Diabetes is a state of chronic hyperglycemia that may result from many environmental and genetic factors often acting jointly

Question 2

What is type 1 diabetes

Answer 2

diabetes.co.uk 2018
-auto immune disease directed at the pancreas which affects the beta cells of the pancreas resulting in an absolute deficiency of insulin
-trigger of auto immune response not specifically identified may be a toxin or virus
-genes play a role
-present underweight at diagnosis
4t’s symptoms
thirst, thinner, toilet, tired

Question 3

what is type 2 dm

Answer 3

-average onset 60
-involves variable degrees of insulin secretion due to beta cell dysfunction and impaired insulin action ie secretion and uptake of insulin is impaired
-slower onset than 1 dm
sympoms often mild or absent initially so can go undiagnosed for many years

Question 4

% of people with dm2 overweight

Answer 4

80% diabetes uk 2009

Question 5

how does obesity cause 2dm

Answer 5

adipose tissue releases inflammatory chemical make body resistance

obesity triggers changes in body’s metabolism causes release of fat molecules into blood stream affect insulin sensitivity

Question 6

prevalence of diabetes

Answer 6

diabetes.co.uk 2018
10% dm1 90% dm 2
-850,000 with 2 dm could be unaware
diabetes uk 2017
3.7 million diagnosed with dm, 4.6 million including those undiagnosed 
nhs dpp, 22,000 die
 early in uk from dm
IDF 2017
425 million worldwide, most 2dm due to ageing pop and obesity

Question 7

treatment diabetes

Answer 7

diabetes.co.uk

Question 8

diagnosis of diabetes

Answer 8

who criteria 2000

-random venous >11.1
-fasting plasma >7
ogtt >11.1

hba1c >6.5%

Question 9

diagnosis of pre diabetes

Answer 9

hbaqc= 6-6.4
ogtt 7.8-11.1
fasting glucose 5.5 to 7

Question 10

complications of diabetes

Answer 10

diabetes.co.uk
macra= cvd
mico= neph, neuro, reti,

Question 11

complications of diabetes and glucose control

Answer 11

Diabetes control and complications trial 1993
-found that improving blood glucose control to a median HBA1C of 7% can reduce development and progression of mico comp by 35-76%
but improving blood glucose had no sig effect on cvd macro suggest important to control other risk factors

Question 12

complications of diabetes and blood pressure control

Answer 12

UKPDS 1998 controlling BP has favourable effects on both macro and micro,
lowering bp to 144/82 sig reduced stroke 44%, heart failure and 37% micro complications

Question 13

normal response and diabetes response to exercise reference

Answer 13

Robertson et al 2014
normal= decrease insulin, increase counterreg hormones, little blood glucose change as balance

dm 1 too much insulin= hypo versus too little insulin= ketosis

dm2 can get hypo if on meds such as insulin or su as otherwise respond normally as reduced hepatic glucose production if on su or insulin

Question 14

reference pa enhances muscle insulin sensitivity

Answer 14

thorell et al 1995

Question 15

what are the main complications for people exercising with dm

Answer 15

1. fear of hypo
2. hypo
3. hyper
4. mico and macra complication

Question 16

reference for fear of hypo

Answer 16

younk, tate and davis 2009 fear of hypo causes overaeating to deliberately run a high BG before/during and after exercise thus the resulting hyper can increase HBA1C

Question 17

what is a hypo

Answer 17

robertson et al 2014
-levels <4mmol/l shake,sweat,lip tingle,pale confused
-confuse with normal exercise response
-1dm or 2dm on meds
harder and longer activities and unfamiliar

Question 18

hypo and youth reference

Answer 18

kelly hamilton and ridell 2010 hypo compromises sport performance by 20% and cognitive function and

Question 19

spontaneous nature of pa in children ref

Answer 19

rowland 1998

Question 20

hyperglycemia causes

Answer 20

type one only
2 situations not enough insulin or short term intensive activity so may need to let bg return to normal and inject insulin fast acting

Question 21

pre-exercise asessment guidelines

Answer 21

ada 2016

• no current evidence that screening beyond the usual care dm reduces risk of exercise induced adverse events in asymptomatic individuals
• pre exercise med clearance no necessary in asymptomatic individuals recieveing dm care

Question 22

sedentary time dm guidelines

Answer 22

coldberg et al 2016

• all adults particulatrly those with 2dm should decrease amount of time spent sitting
• prolonged sitting should be interrupted with light bouts of activity every 30 minutes for blood glucose benefits at least in adults with 2dm
• addition to other exercise

Question 23

sb time evidence for dm

Answer 23

coldeberg et al 2016

• higher amounts of sedentary time are assoc. to increase mortality and morbidity mostly independent of mvpa
• in people with or at risk of developing 2dm, extended sedentary time is also assoc. to poorer glycemic control and clustered metabolic risk
• prolonged sitting interrupted by brief bouts of standing/ light pa every 20/30 mins improves glycemic control

van dijk etal 2013, dempsey etal2016
in adults with 2dm interrupted prolonged sitting with 15 min postmeal walk or 3min lightpa/ sra every 30 mins imrpoves glycemic control

Question 24

pa recommendations for 2dm

Answer 24

coldberg et al 2016

1. daily exercise or at least not allowing more than 2 days to elapse between exercise sessions is recommended to enhance insulin action
2. combined aerobic and rt
3. children meet norm pa guidelines
4. structured lifestyle intervention incl.150 mins week and 5-7% weight loss
5. flexibility and balance important for peripheral neuropathy
6. increase daily (3-15 minutes) movement to reduce postprandial hyper and reduce SB
7. Coldberg et al 2010 3x week, no more than 2 consecutive days, 40-60%, min 150 minutes a week large muscle group
8. Coldberg et al 2010 Resistance training 2x week, non consec days, 50% 1pm mod 60-80% vid 5-10 exercises 10-15 reps, 1-4 sets
9. Coldberg et al 2010 supervised training
10. ADA 2016 for weight loss with 2 dm recommend 500-700kcal/ day energy deficit with reduced calorie diet and 200-300 min/week pa
11. 11. O’Halloran and Bhogal 2014 states gradually building up the number of steps to 10,000 steps a day and increasing to 15,000 steps a day in order to loose weight.

Question 25

ronald et al 2004

Answer 25

duration insulin sensitivity not more than 72 hrs

Question 26

pa guideline 1dm

Answer 26

coldberg - youth and adults 1dm benefit from pa - blood glucose responses to pa in all people with 1dm are highly variable, based on activity type and timing - additional card/ insulin reduction required to main balance during and after - insulin can use either basal bolus or insulin pump - use CGM to detect hypo

Question 27

general recommendation for pa

Answer 27

coldberg - asssess unecessary - same guidelines as adults norm 150 spread over 3 days no more than 2 consec - encourage increase incidental to pa - to gain more health benefit supervised over non - behaviour strategies - tolerable step targets - flexibility2-3x week older

Question 28

pa recommendation avoid hypo

Answer 28

robertson etal 2014 - activity - carbs before and after hypo 24hrs - avoid exercise when insulin peak - alter insulin dose - CGM - subcut injection - dont inject into site used in pa - nocturnal hypo coldberg - short sprint in aerobic - insulin pump nagi and gallen 2010

Question 29

pa recommendation for specifc complications

Answer 29

coldberg nagi and gallen - peripheral neuropathy - autonomic neuropathy: heat and bp - retinopathy-avoid bp increase - cvd keep <10bpm angina onset - nephropathy exercise undertaken safely but fine

Question 30

pa references evidence for 2dm PREVENTION

Answer 30

1. Tuomileto et al 2001 2. Knowler et al 2002 3. healthier you 2016 4. Aguiar et al 2014

Question 31

pa and 1dm evidence

Answer 31

1.cuenca garcia 2. macmillan et al 2014 3, chimen et al 2012 4.quirk et al 2014 5. yardley et al 2014 6. waden et al 2015

Question 32

pa and 2dm evidence

Answer 32

1. dempsey et al 2016 2. thomas et al 2006 3. Umpierre et al 2011 4. Avery 2012

Question 33

tuomileto et al 2001

Answer 33

522 people IGT Ig individualised advice on pa, diet and weight cg standard care alone 3.2 yr follow up progression to 2dm 58% lower in IG compared to cg and mean body weight diff higher 4.2 versus 0.8

Question 34

knowler et al 2002

Answer 34

3 groups placebo, drugs metformin x2, and lifestyle advice group 16 week 7% wl aim 3234 IGT participants lifestyle 58% lower and 31% lower in pharama compared to placebo group 1/2 ethnic minority

Question 35

aguiar et al 2014

Answer 35

- sr and ma of multi component lifestyle intervention - diet aerobic and rt intervention commbined - 12 months median, follow up 18 month - on average asked to perform aerobic exercise 5xweek, 157.5 mins week, RT 2.3 days week, average duration 90 mins a week - MA sig reduction in weight, fast placma g in IG over CG - concluded multi component at least 150 mins, 60 mins rt effective induce weight loss and diet

Question 36

cuenca garcia et al 2012

Answer 36

using accelerometer found mvpa associated to better glycaemic control and accounted for 30-37% of variance in PA young people 1dm97

Question 37

macmillan et al 2014

Answer 37

sr 11 studies included youth with dm 1 intervention ranged 8 to 24 weeks, most 12 weeks -7 aerobic,3 combined 1 pilates -MA found benefits to HBA1C were associated to longer programs >12 weeks, more frequent >3 days a week and longer duration >60 minutes and include combined aerobic and RT limitations: small sss, 2 reported adherence to intensity

Question 38

chimen et al 2012

Answer 38

aerobic training in 1 dm increases crf, improve lipid, endothelial function found increase of up to 27% vo2 reported in vo2 from supervised pa program -depending on intensity of intervention reduces HBA1C about 4.2mmol/s -incidence of depression 3x higher and improves well being -both rt and endurance improved insulin sensitivity up to 23 %

Question 39

quirk et al 2014

Answer 39

``` st and ma 23 studies youth with dm 1 interventions: 2-29 week ,modal 12, 30-120 mins , 1-5x, combined or aerobic 65-74% for mod, >75% vig RESULTS of MA -hba1c= -0.52 mean diff -no diff in insulin dose -lipids mean diff -0.91 for total cholesterol and bmi decreased ```

Question 40

yardley et al 2014

Answer 40

sr and ma adults 1dm 6 rct 2xweek to daily, 50-90% 20-120 mins, 2month min combined or aerobic RESULTS decrease -0.78% compared to controls exercise training improved CRF by 3.45 ml.kg.min compared to control but poor method reporting with withdrawal and concealment hard to ascertain risk bias

Question 41

waden et al 2015

Answer 41

prospective study 6.4 yrs follow up total amount of leisure time pa not assoc. to progression of renal status but demonstrated that intenstiy and freq may be with higher intensity and >2 x week lower progression rate but self report data for intensity

Question 42

dempsey et al 2016

Answer 42

sb in 2dm adults 3 groups SIT, LWA 30 mins 3min walk, SRA, 30 mins resistance. done for 8 hours 3 separate dats only 24 participants, longer effects needed -compared to SIT both activity sig attenuated acute postpranidal glucose, insulin, cpep and trig response. sit 24.2, lwa 14.8 and sra 14.7 mmol.l

Question 43

umpierre et al 2011

Answer 43

sr and ma -pa advice versus structured exercise 47 RCT PA >12 WEEKS compared to control groups aerobic 0.73% resistance 0.57% and combined 0.71% hba1c -structured exercise >150 mins assoc to larger decrease -0.89% pa advice no change pa +diet advice -0.58% change quality of studies low increase risk of bias

Question 44

thomas et al 2006

Answer 44

``` cochrane review 2dm 14RCT exercise vs none 8-12 week duration 3 sessions per week, non-consec aerobic and RT mix either progressive rt or mod aerobic RESULTS -compared to cg the ig sig improved glycaemic c as hba1c -0.6& - decrease visceral adipose tissue with exercise and subcut -increase insulin response -decrease plasma trig primary studies none reported blinding 7. Found improvements in glycaemic control achieved from low to high intensities no study reported adverse events ```

Question 45

avery 2012

Answer 45

sr and ma behavioural intervention 2dm 17 RCTs behavioural showed statistically sig increases in objective and self-monitoring pa -sig improved hba1c and bmi ->4 weeks duration on free living pa and exercise -hba1c 6month -0.33, 12 -0.33 & 24 -0.56% found at least 10 diff behaviour change techniques assoc. to clinically sig improvement in hba1c >0.3% esp. prompting generalization of a target behaviour, prompts follow up, prompt goals review, social support, time management and problem solving with identifying barriers

Question 46

hamman et al 2006

Answer 46

found that for every kg of weight loss it reduced the risk of developing type 2 diabetes by 16% in participants with a bmi of >24

Question 47

ahn and song 2012

Answer 47

a. Tai chi on exercise control, neuropathy, balance and hrqol in patients with 2dm and neuropathy b. 59 dm patients with neuropathy c. 1 hr tai chi, 2x week for 12 weeks d. 34% drop out rate e. Compared to a control group HbA1c was sig better, balance, neuropathic symptoms and some dimension of qol

Question 48

morrison et al 2010

Answer 48

a. Balance training as 2dm are at increase risk falling due to impairment in posture and gait b. Small sample size c. Older adults with 2dm d. 6 week 3x week exercise program consisting of balance posture and resistance strength of 1-2 sets of 10-12 reps e. Dm individuals had a higher fall risk score compared to CG f. But dm group showed sig improvement in leg strength, faster reaction time, decrease sway and consequently reduced falls risk after 6 weeks

Question 49

jelleyman et al 2016

Answer 49

a. High intensity inverval training on glucose and insulin b. Meta analysis c. Either aerobic interval, sit or hit d. Compared to control group and to continuous training there was a reduction in insulin resistance, e. Compared to control group HBA1C decreased 0.19% and body weight decreased 1.3 kg f. Participants with 2dm exepericed reduction in fasting glucose -0.92mmol l compared to control group g. There were more exercise related injuries reported in HIIT than control but limited reporting

Question 50

qiu et al 2014

Answer 50

a. Systematic review and meta analysis of walking and 2dm b. 18 studies c. Walking sig decreased HbA1c by 0.5% d. Supervised walking assoc. to greater pronounced decrease in HbA1c -0.58 whereas non-supervised walking was not e. Non supervised but with motivational strategies is effective in decreasing HBa1C -0.53% f. Walking also sig reduced body mass, lowered BP and changed HDL or LDL cholesterol g. Most overweight so walking only option