Metabolic Diseases: Obesity, Hyperlipidemia, and Diabetes

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1 Metabolic Diseases: Obesity, Hyperlipidemia, and Diabetes Obesity Approximately 1 in 3 adults are overweight in the U.S. Arizona According to CDC, Arizona has highest reported percentage of adults who eat fewer than 5 servings of fruits and vegetables per day and the highest percentage of adults who report no physical activity; 65% of mean overweight; 37% of women Obesity Trends Among U.S. Adults between 1985 and 2000 Source of the data: The data shown in these maps were collected through CDC s s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults 1

2 Obesity* Trends Among U.S. Adults BRFSS, 1990 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC. Obesity* Trends Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC. Obesity* Trends Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC. 2

3 Obesity* Trends Among U.S. Adults BRFSS, 1997 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC. Obesity* Trends Among U.S. Adults BRFSS, 1999 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: BRFSS, CDC. Obesity* Trends Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs overweight for 5 4 person) No Data <10% 10%-14% 15-19% 20% Source: Mokdad A H, et al. JAMA 2001;286:10 Criteria for Obesity 3

4 Consequences of obesity Comorbid conditions Coronary Heart Disease Hyperlipidemia Cancers Type II Diabetes Mellitus Hypertension Orthopedic conditions Mortality Criteria for Obesity Overweight height and weight charts BMI Government standards - (i.e. Surgeon General) Body mass index (BMI) Obesity Body composition 22 25% for men; % for females 130% ideal body weight Some argue that 120% of ideal body weight should be used for classification 4

5 Methods used to evaluate levels of obesity Hydrostatic weighing Pinch and inch (skinfolds) Body circumference measures Waist to hip Optimal for men < 0.95 Optimal for women <0.85 Evaluates risk for disease How do we become obese...in theory? Intake Expenditure Intake Expenditure Expenditure Intake Body type may be important 5

6 Obesity: Exercise Training Acute exercise response Reduced functional capacity Increased cardiac work for a given submaximal load. Exercise intolerance due to orthopedic limitations and/or hyperthermia Exercise training Cardiovascular system Decreased blood pressure response, improved blood lipid profile Respiratory system In the grossly obese, may see improvement in ERV and blood gasses. Obesity: Exercise Training Exercise training (con t) Metabolism Metabolism Lowering of insulin concentrations (improved sensitivity) Lower VLDL and triglycerides, increased HDL General Health Best improvements in those who move out of severe obesity status Bray et al. procedures that reduce intake were shown to have greater potential for reducing weight and stored fat than those that increased energy expenditure. Weight fluctuation may have indirect effect on CHD, cancer, and all-cause mortality Obesity: Exercise Testing and Prescription Mode (Peak Met level = 6 8 METs) Cycle ergometer Treadmill use very low intensity warm-up with 1-21 MET increases Prescription F = 5 days/wk + I = low to moderate intensity (50 to 70% of peak capacity) Time = 40 to 60 minutes total Type = walking, cycle ergometer, water exercise Strength training maintaining or gain lean body weight 6

7 Obesity: Special Considerations Injury History Adequate, warm-up, and cool-down Gradual progression Low or non-weight bearing exercises Thermoregulation Exercise at cool times of day with adequate water, and loose fitting clothing Diabetes Chronic metabolic disease characterized by absolute or relative deficiency of insulin 17 million Americans have diabetes (1/3 don t know they have it) (CDC, 2000) 2 to 4 X risk for MI and stroke; leading cause of end-stage renal disease, blindness, and lower extremity amputation 7

8 Types of Diabetes Type I Insulin Dependent Diabetes Mellitus Type II Non-Insulin Dependent Diabetes Mellitus Gestational occurring during 2 nd or 3 rd trimester of pregnancy Secondary due to other diseases, medications, etc Impaired Glucose Tolerance elevated fasting glucose (> 140mg/dl), but may not progress to full blown diabetes. Diagnosis Symptoms plus casual plasma glucose 200 mg/dl Or Fasting plasma glucose 126mg/dL 2 hour plasma glucose 200 mg/dl during OGT test *HbA1c - > 7 percent IDDM Type I Diabetes Absolute deficiency of insulin due to an autoimmune response directed at the beta cells in the pancreas leading to their destruction 10 to 15% of cases are IDDM Must supply insulin via injection or an insulin pump 8

9 NIDDM Type II Relative insulin deficiency due to peripheral tissue insulin resistance and defective insulin secretion. If beta cells become exhausted, may have to use insulin injection. 80% of those with Type II are obese at onset Usually occurs after the age of 40, and many may not realize they have it. Diabetes: Exercise Training Exercise response - disturbance of peripheral glucose utilization and production is disturbed and is dependent upon Medications timing, use, type, etc Blood glucose level prior to exercise Food intake timing, amount, type, etc Severity of diabetic state F.I.T.T. of exercise Diabetes: Exercise Training Exercise training Improved glucose control Improved insulin sensitivity Body fat reduction Decreased risk of CVD Stress reduction as a means to improve regulatory hormones Prevention of Type II diabetes 9

10 Diabetes: Chronic Complications 1. Macrovascular coronary artery disease, MI, stroke, etc. 2. Microvascular retinopathy and nephropathy 3. Neuropahty peripheral and autonomic nervous system See Figure 8.3 Diabetes: Exercise testing Mode (Peak Met level = 5 7 METs) Cycle ergometer Treadmill use very low intensity warm-up with 1-21 MET increases Do not test if resting blood glucose > 250 mg/dl Be ready for SxS involving Hypoglycemia Neuropathy Microvascular complications Angina or masked angina (in those taking beta-blockers) blockers) Diabetes: Exercise prescription Prescription Frequency = 4-7 days/wk + Intensity = low to moderate intensity (50 to 90% of peak capacity) Time = 20 to 60 minutes total Type = walking, cycle ergometer, water exercise Precautions Snack Monitor blood glucose before and after exercise Exercise earlier in the day Angina 10

11 Diabetes: Exercise Programming Individualization is key relative to timing of exercise session Food intake Medication use Foot care (shoes, socks, etc) Medical identification Diabetes: Medications and Management Depends on type of diabetes Need to be aware of onset, peak, and duration Insulin allows glucose in enter insulin sensitive tissue Animal Human Oral hypoglycemic agents help pancreas to secrete more insulin Sulfonylureas Metformin increases insulin sensitivity, lowers cholesterol, and suppresses appetite Hyperlipidemia: Exercise Training May Lower triglyceride concentrations Increase HDL concentrations Increase enzyme activity 11

12 Hyperlipidemia Classes Chylomicrons Very low-density lipoproteins Low-density lipoproteins High-density lipoproteins Interplay between genetic, environmental, and pathologic factors can alter cholesterol and triglyceride transport Hyperlipidemia: Exercise Testing and Prescription Testing Standard testing used for most cardiac disease populations depending on initial Dx Prescription Largely depends on other comorbid conditions Frequency = 5-7 days/wk + Intensity = low to moderate intensity (40 to 70% of peak capacity) Time = 40 minutes Type = walking, cycle ergometer, water exercise Hyperlipidemia: Medications and Management Diet Weight loss Drug therapy Often use combination of several medications High risk of rhabdomyolysis Medications Nicotinic acid (niacin) 12

13 Hyperlipidemia: Medications con t Bile acid-binding resins (colestipol( colestipol) Fibric acid derivatives (gemfibrozil( gemfibrozil) Hepatic hydroxymethyglutaryl conenzyme A reductase inhibitors ( statins( statins ) Probucol Hyperlipidemia: Medication Interactions Medications that may effect lipids indirectly Beta blockers Thiazide diuretics Insulin or OHA s Levothyroxine Oral contraceptives Estrogen and Progesterone 13

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