Barbara Schlichte
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Father diagnosed with
Type 2
Father-in-law died
from complications
with type 2
Genetics
Dad
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Definition of Diabetes Mellitis
Epidemiology
Clinical Aspects
Treatment
Effects of Exercise
Exercise Testing
Exercise Prescription
Summary
Conclusion
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Diabetes mellitus is a group of diseases
characterized by high blood glucose
concentrations resulting from defects in
insulin secretion, insulin action, or both.
Abnormalities in metabolism of CHO, protein
and fat are present.
People with diabetes have bodies that don’t
produce or respond to insulin.
Without effective insulin, hyperglycemia
(elevated blood glucose) occurs.
 Type
1
 Type 2
 Gestational
 Other types
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Absolute deficiency of insulin
Marked reduction of beta-cells in pancreas
Thought to involve an autoimmune
response-no known means to prevention
Exogenous insulin must be supplied
Prone to ketoacidosis
Accounts for 5% to 10% of diagnosed cases
Can occur at any age although most
affected people are children and young
adults
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Relative insulin deficiency-insulin resistant
◦ Elevated, reduced or normal insulin levels
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Risk factors include: (test on diabetes
website)
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Genetics
Older age
Obesity (particularly abdominal)
Sedentary lifestyle
Gestational diabetes
Pre-diabetes
Race or ethnicity
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Most cases do not require exogenous
insulin
Do not develop ketoacidosis except in
cases of unusual stress
Accounts for 90% to 95% of diabetes
cases
Usually occurs after the age of 40 but is
developing in young adults and youth
NO CURE-only management!
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Glucose intolerance
during pregnancy
Due to contrainsulin effects of
pregnancy
20% to 50% of
women with
gestational diabetes
develop type 2
within 5 – 10 years
Gestational
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Results from specific
genetic syndromes,
surgery, drugs,
malnutrition,
infections, or other
illnesses
Depending on
pathophysiology,
may or may not
require insulin
Other types
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Total: 25.8 million children and adults in the
US-8.3% of the population have diabetes
Diagnosed: 18.8 million
Undiagnosed: 7 million
Pre-diabetes: 79 million
New Cases: 1.9 million new cases were
diagnosed in 2010
Cost: $174 billion! In 2007
Medical costs are 2.3 times more for
diabetics
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Percentage of Ethnic Group with type 2 diabetes
7.1%
8.4%
12.6%
11.8%
Non-Hispanic
Asian
Non-Hispanic
Hispanics
whites
Americans
blacks
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Frequent urination
Extreme thirst
Extreme hunger
Unusual weight loss
Extreme fatigue and
irritability
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Type 1
Any of the type 1
symptoms
Frequent infections
Blurred vision
Cuts/bruises that are
slow to heal
Tingling/numbness in
hands/feet
Recurring skin, gum or
bladder infections
OR NO symptoms!
Type 2
Diagnosis
Criteria
Diabetes
FPG≥126 mg/dl
CPG≥200 mg/dl
2hPG≥200 mg/dl
Pre-diabetes
Impaired fasting glucose
Impaired glucose tolerance
Normal
FPG100-125 mg/dl
2hPG140-199 mg/dl
FPG<100 mg/dl
2hPG<140 mg/dl
*2bPG, 2-hour plasma glucose
level
*FPG, fasting plasma glucose
* CPG Casual plasma glucose
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Adults with
diabetes have heart
disease death rates
2 to 4 times higher
than those without
diabetes
Adults with
diabetes have a 2 to
4 times greater risk
of having a stroke
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In 2005-2008,
67% of adults
with diabetes
had high blood
pressure
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Diabetes is the
leading cause of
new cases of
blindness in
adults ages 20 to
74
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Leading cause of kidney failure in US
◦ Accounts for 44% of cases in 2008
Neuropathy-about 60% to 70% of
diabetics have some form of nerve
damage
 Amputation-about 60% of nontraumatic lower limb amputations
occur in diabetics
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 Insulin
therapy
◦ Type 1
◦ Some type 2
 Individual
nutritional care plan
 Exercise-especially for type 2
 Oral medication/type 2
Generic name
Rapid acting
Insulin lispro
Insulin aspart
Insulin glulisine
Short acting
Regular
Intermediate
acting
NPH
Lente
Long acting
Insulin glargine
Ultralente
Trade
Name
Humalog
NovoLog
Apidra
Humulin R
Novolin R
Onset
<15 min
Peak
30-90 min
Duration
1-3 h
3-6 h
30-60 min
2-3 h
2-4 h
4-10 h
10-16 h
2-4 h
Does not
peak
18-36 h
Humulin N
Novolin N
Humulin L
Lantus
Humulin U
Generic name
Trade name
Biguanides
Metformin
Metformin(liquid)
Glucophage, Glucophage XR,
Riomet
Glucosidase
inhibitors
Acarbose
Miglitol
Meglitinides
Nateglinide
repaglinide
Precose
Glyset
Starlix
Prandin
Concerns with
exercise
May produce
hypoglycemia with
postprandial
exercise
May produce
hypoglycemia with
postprandial
exercise
Generic name
Secretagogues
Acetohexamide
Chlorpromide
Tolazimide
Tolbutamide
Glimepride
Glipizide
Glyburide
Thiazoladinediones
Pioglitazone
Rosiglitazone
Dipeptidyl peptidase4 inhibitors
Sitagliptin
Trade name
Generic only
Diabinese
Tolinase
Orinase
Amaryl
Glucotrol, Glucotrol XL
Diabeta, Glynase,
PresTab, Micronase
Actos
Avandia
Januvia
Concerns with
exercise
Can produce
hypoglycemia during
or after exercise
No hypoglycemia
unless given with
another drug
Generic name
Trade name
Comments and concerns with
exercise
Exantide
Byetta
Exantide is used in treatment of
type 2 and is found to increase
postprandial insulin response,
delay gastric emptying,
suppress glucagon secretion,
and reduce appetite
Pramlintide
Symlin
Pramlintide is a synthetic
hormone similar to human
amylin. It may be used in
combination with insulin
therapy for treatment of either
type 1 or 2. Pramlintide works
by suppressing glucagon
secretion and delaying gastric
emptying.
Insulin and counter
regulatory hormones
don’t respond to
exercise in the
normal manner
Balance between
peripheral glucose
utilization and
hepatic glucose
production may be
disturbed=
hypo/hyperglycemia
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Insulin allows glucose to enter the cells of
insulin-sensitive tissue
Oral and injectable agents for type 2 diabetes
are meds that help the pancreas secrete more
insulin, alter CHO absorption, reduce liver
glycogenolysis, increase insulin sensitivity, or
a combination of effects
Meds may cause hypoglycemia
◦ Pay attention to med timing, food intake, blood
glucose level before and after exercise
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Muscle contractions increase glucose
uptake
Both aerobic and resistance exercises
increase GLUT4 abundance and BG uptake
Insulin action and glucose tolerance is
increased (type 2)
Dependent on several factors
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Use and type of meds to lower blood glucose
Timing of meds
Blood glucose level prior to exercise
Timing, amount, and type of previous food intake
Presence and severity of diabetic complications
Use of other meds
Intensity, duration and type of exercise
Weight loss (type 2)
 Improved insulin sensitivity
 Possible prevention of type 2
 For those with type 2-possible
improvement in blood glucose control
 Improved CV health
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◦ Lower triglycerides
◦ Lowers blood pressure
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Exercise testing using protocols for
populations at risk for CAD recommended in
individuals who:
Have type 1 and are over 30 yrs
Have had type 1 longer than 15 years
Have type 2 and are over 35 yrs
Have either type 1 or 2 and one or more other CAD
risk factors
◦ Have suspected or known CAD, or
◦ Have any microvascular or neurological diabetic
complications
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Methods
Measures
endpoints
Aerobic
Cycle (ramp protocol
17 W/min; staged
protocol 25-50 W/3
min stage)
Treadmill (1-2
METs/stage)
12-lead ECG, HR
Serious dysrhythmias
>2 mm ST-segment
depression or
elevation
Ischemic threshold
Significant T-wave
change
BP
RPE (6-20)
SBP >250 mmHg or
DBP >115 mmHg
Onset of peripheral
pain
People with diabetes who don’t meet
any of the criteria for CAD may be
tested with use of protocols for the
general healthy population
 Primary objectives are to:
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◦ Identify the presence and extent of CAD
◦ Determine appropriate intensity range for
aerobic exercise training
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Must be individualized according to med
schedule, presence and severity of diabetic
complications, and goals of program
Hypoglycemic meds=additional 15 g of CHO
before or after exercise
15 to 30 g CHO (fat free) every hour during
vigorous or exercise>60 min
Proper hydration
Good foot care-proper shoes and socks
Athletes will most often know their limits but
trial and error with beginners-monitor BG!!
Active retinal hemorrhage or recent
retinopathy therapy
 Illness or infection
 Blood glucose >250 mg/dl and
ketones are present
 Blood glucose <70 mg/dl
 If blood glucose is <100 mg/dl, CHO
should be consumed
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Modes
Goals
Intensity/frequenc
y/duration
Time to goal
Aerobic
Large muscle
activities
Increase aerobic
capacity, time to
exhaustion, work
capacity, BP
response to
exercise,
Reduce CV risk
factors
50-80% peak HR
50-80% VO2peak
Monitor RPE
4-7
sessions/week
20-60
min/session
4-6 month
Strength
Free weights
Weight
machines
Elastic tubing
or bands
Increase max reps
Improve
performance for
competitive
patients
low resistance,
high reps for most
High resistance
OK for patients
with well
controlled diabetes
4-6 months
Modes
Anaerobic
High-intensity
intervals
Goals
Time to goal
Only for athletes Same as for
in good diabetic nondiabetic
control
athletes
Flexibility
Stretching/yoga
Maintain/
increase ROM
Improve gait
Neuromuscular
Yoga
Improve
balance and
coordination
Functional
Activity-specific
exercise
Intensity/freque
ncy/duration
Increase ADLs
Increase
vocational
potential
Increase self
confidence
Limited data; 23 x’s/week may
suffice
Individualized to
each client
4-6 months
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Diabetes song
http://www.youtube.com/watch?v=Ni8lwD7Z
0c8
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Diabetes is a disease that should be taken
seriously
Some type 2 can be managed with diet and
exercise
If there are no significant complications with
diabetes mellitus, patients can enjoy exercise
with very few limitations
Exercise for type 2 patients is a must!!
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American College of Sports Medicine, A. D. (2010). Exercise and
type 2 diabetes. Medicine and Science in Sports & Exercise.
Diabetes Statistics. (n.d.). Retrieved February 24, 2012, from
American Diabetes Association: www.diabetes.org
Durstine, J. M. (2009). ACSM's Exercise Management for Persons
with Chronic Diseases and Disabilities. Champaign: Human Kinetics.
Farrell, P. (2003). Diabetes, exercise and competitive sports.
Gatorade Sports Science Institute Sports Science Exchange , 1-6.
LaFontaine, T. (2004). Exercise considerations for individuals with
type 1 diabetes. Strength and Conditioning Journal , 16-18.
Mahan, L. E.-S. (2008). Krause's Food and Nutrition Therapy. St.
Louis: Saunders Elsevier.