EXERCISE TIPS FOR PEOPLE WITH DIABETES Ron Sigal, MD, MPH, FRCPC rsigal@ucalgary.ca Professor of Medicine, Cardiac Sciences, Kinesiology & Community Health Sciences, Cumming School of Medicine, University of Calgary Health Senior Scholar, Alberta Innovates-Health Solutions
Outline How much exercise should people with diabetes perform? Why? What are some new strategies to reduce risk of exercise-induced hypoglycemia (low blood sugar) in people with type 1 diabetes? Why should people with diabetes do strength training (resistance exercise)?
I have no conflicts of interest to declare
Acknowledgments Operating support: Canadian Institutes of Health Research Canadian Diabetes Association The Lawson Foundation Salary support: R. Sigal: Health Senior Scholar, Alberta Innovates-Health Solutions G. Kenny: University Research Chair, University of Ottawa B. Perkins and Jane Yardley: Canadian Diabetes Association
Marni Armstrong, PhD Candidate Author of slides with black background
Exercise Planned, structured physical activity.
Types of exercise Aerobic exercise Exercise involving continuous, repeated movements of large muscle groups. E.g. brisk walking, running, bicycling Resistance exercise (strength training) Exercise involving weight lifting or movement of muscles against resistance E.g. exercise with free weights, weight machines
Current Canadian Diabetes Association (CDA) guidelines At least 150 min/week of moderate to vigorous aerobic exercise spread out during at least 3 days during the week, with no more than 2 consecutive days between bouts of aerobic activity. Resistance training at least twice per week, and ideally 3 times per week, in addition to aerobic training. Initial instruction and periodic supervision by an exercise specialist are recommended. Sigal RJ et al, Can J Diabetes 2013; 37(Suppl 1):S40-S44.
Why 150 minutes of aerobic exercise?
Why 150 minutes? 2008 US Physical Activity Guidelines Advisory Committee Report: For studies classifying subjects by energy expended, it appears that some 1,000 kilocalories per week or 10 to 12 MET-hours per week (approximately equivalent to 2.5 hours per week of moderate-intensity activity) or more is needed to significantly lower the risk of: all-cause mortality coronary heart disease stroke hypertension type 2 diabetes
Evidence from trials in type 2 diabetes
Absolute changes in HbA1C of individual studies structured exercise training vs. no intervention, according to weekly amount of exercise Umpierre, JAMA, 2011; 305, (17); 1790-99 Reduction of - 0.89% in HbA1C Reduction of 0.36% in HbA1C
Are resistance training and strength clinically important?
Strength is clinically important Biological aging: lose strength and lean body mass Older patients with type 2 diabetes have an accelerated decline in muscle mass and strength when compared with age-matched nondiabetic controls Strategies to maintain muscular strength enhance mobility and functional independence further into old age are important
Strength is clinically important Large long-term cohort study: bottom tertile of strength was associated with: 23% higher all-cause mortality 32% higher cancer mortality 29% higher heart disease mortality Ruiz JR. BMJ 2008; 337:a439. Ruiz JR. Cancer Epidemiol Biomarkers Prev Med 2009;18(5):1468-1476.
Resistance training is clinically important Large long-term cohort study: Regular resistance training was independently associated with 23% reduction in heart disease risk even after adjustment for age, smoking, alcohol, diet, and all other physical activity. Tanasescu M. JAMA 2002; 288(16):1994-2000. Tanasescu M. Circulation 2003;107(19):2435-2439.
Combined aerobic and resistance exercise is probably best
The Diabetes Aerobic and Resistance Exercise (DARE) Trial RJ Sigal, GP Kenny, NG Boulé, RD Reid, D. Prud homme, M. Fortier, D. Coyle, GA Wells Funding: Canadian Institutes of Health Research Canadian Diabetes Association Sigal RJ et al. Ann Intern Med 2007; 147:357-369.
DARE trial: Design Randomized, controlled trial 4-week pre-randomization run-in period to assess compliance Randomization to Aerobic Training only Resistance Training only Both Aerobic and Resistance Training Waiting-list Control
Results: A1c (%) changes over time Baselin e 3 mo. 6 mo. Change from 0-6 mo. Adj mean (95% CI) P-value Combined 7.46 6.99 6.56-0.90 <0.001 n=64 (1.48) (1.56) (0.88) (-1.15 to -0.64) (40M,24F) Aerobic 7.41 7.00 6.98-0.43 0.002 n=60 (39M,21F) (1.50) (1.59) (1.50) (-0.70 to -0.17) Resistanc e n=64 (40M,24F) 7.48 (1.47) 7.35 (1.57) 7.18 (1.52) -0.30 (-0.56 to -0.05) 0.018 Control n=63 (41M,22F) 7.44 (1.38) 7.33 (1.49) 7.51 (1.47) +0.07 0.57 (-0.18 to +0.32)
HbA1c, % HART-D: Health Benefits of Aerobic & Resistance Training in Individuals with Diabetes Church T, JAMA. Nov 24 2010;304(20):2253-2262. 7.80 Intention-toTreat Analysis (n=262) 7.70 Control 7.60 7.50 7.40 Resistance Aerobic Combo 7.30 7.20 0 1 2 3 4 5 6 7 8 9 Month
Italian Diabetes and Exercise Study 606 patients with type 2 diabetes and metabolic syndrome All received exercise counseling Randomized to control group (usual care plus exercise counseling) or intervention group (prescribed and supervised aerobic and resistance exercise training) for 12 months Balducci S et al, Arch Intern Med 2010
IDES: Supervised exercise was superior for HbA1c Systolic and diastolic blood pressure BMI Waist circumference Aerobic fitness Muscle strength HDL cholesterol Estimated 10-year cardiac risk
What strategies can reduce exercise-induced hypoglycemia in type 1 diabetes?
Strategies to reduce risk of hypoglycemia from exercise in T1DM Adjust insulin. Adjust carbohydrate intake. Short (10-second) sprints before, during or at the end of exercise. Perform resistance exercise before aerobic exercise.
Short sprints Interventions involving anaerobic activity (short sprints) have shown some promise for avoidance of hypoglycemia http://www.sevenseeds.org 3
Acute effects of short sprints 10-sec sprint at end of exercise 4-sec sprint every 2 minutes Intermittent sprint group 10-sec sprint group From Bussau, VA et al. Diabetes Care 2006; 29: 601-6. From Guelfi, KJ et al., Diabetes Care 2005; 28(6):1289-94. 4
10-second sprint at beginning of exercise 10-sec sprint group Bussau VA et al, Diabetologia 2007
Strategies to reduce risk of hypoglycemia from exercise in T1DM Adjust insulin. Adjust carbohydrate intake. Short (10-second) sprints before, during or at the end of exercise. Perform resistance exercise before aerobic exercise.
Jane Yardley, PhD
Design Participants performed five exercise sessions in random order followed by 1 hour of monitored recovery separated by at least 5 days: 1) No exercise (45 minutes seated resting) 2) Aerobic exercise (45 minutes treadmill running at 60% VO 2peak ) 3) Resistance exercise (3 sets of 8 repetitions (8RM)) 4) Aerobic then resistance exercise 5) Resistance then aerobic exercise 7
Participants N 12 (10 male, 2 female) Age (yrs) 31.8 15.3 Ht (m) 1.77 0.07 Wt (kg) 79.2 10.4 BMI (kg/m 2 ) 25.3 3.0 VO 2peak (L/kg min) 51.2 10.8 Hemoglobin A 1c (%) 7.13 1.1 Diabetes Duration 12.5 10.0 Insulin delivery MDI = 5, insulin pump = 7 10
Aerobic exercise vs. resistance exercise vs. control Yardley JE, Kenny GP, Perkins BA, Riddell MC, Balaa N, Khandwala F, Malcolm J, Boulay P, Sigal RJ. Resistance versus aerobic exercise: acute effects on glycemia in type 1 diabetes. Diabetes Care 2013 Mar;36(3):537-542. 11
Aerobic vs. resistance exercise Control Resistance Aerobic - control - aerobic exercise Δ - resistance exercise a significant change from baseline (aerobic) b - significant change from baseline (resistance) c significant difference between aerobic & control d significant change throughout recovery (aerobic) 12
Resistance-then-aerobic (RA) vs. aerobic alone (A) Presented as an oral abstract at the 2011 CDA/CSEM National Conference: Yardley JE, Kenny GP, Perkins BA, Riddell M, Malcolm JS, Sigal, RJ. Declines in Blood Glucose During Aerobic Exercise are Attenuated by Prior Resistance Exercise. Can J Diabetes (Suppl.), 2011. 16
Resistance-then-Aerobic vs. Aerobic only - resistance then aerobic exercise - aerobic exercise alone * - significant change from baseline - significant change throughout recovery 17
Resistance then Aerobic (RA) vs. Aerobic then Resistance (AR) Yardley JE, Kenny GP, Perkins BA, Riddell MC, Malcolm J, Boulay P, Khandwala F, Sigal RJ. Effects of performing resistance exercise before versus after aerobic exercise on glycemia in type 1 diabetes. Diabetes Care. 2012 Apr;35(4):669-75. 20
Resistance then Aerobic (RA) vs. Aerobic then Resistance (AR) RA AR - resistance then aerobic exercise - aerobic then resistance exercise * - significant change from baseline - significant difference between treatments - significant change throughout recovery 21
Summary: acute effects of aerobic and resistance exercise in T1DM In physically-fit individuals with type 1 diabetes with good glycemic control: Resistance exercise on its own was associated with less acute glucose-lowering and a lower need for supplemental glucose than aerobic exercise on its own In sessions combining aerobic and resistance exercise, performing resistance exercise prior to aerobic exercise decreases the need for carbohydrate intake during exercise and may reduce the risk of exercise-induced hypoglycemia during aerobic exercise.
How important is it to avoid sedentary behaviour?
Sedentary Behavior
Cumulative Survival, % Canada Fitness Survey of 1981: 7278 men and 9735 women, aged 18 90 yr Daily Sitting Time Katzmarzyk, MSSE, 2009 41(5):998-1005 Follow-up years
Age Adjusted All Cause Death Rate per 10,000 person years Canada Fitness Survey of 1981: 7278 men and 9735 women, aged 18 90 yr Katzmarzyk, MSSE, 2009 41(5):998-1005
Back to strength training
Resistance training (strength training) is recommended for people with diabetes, but participation rates are low. Cost of gym membership. Travel to gym. Discomfort with gym environment.
Could training with resistance bands be the solution?
Resistance bands training (vs. gym-based training) Much lower costs. Greater feasibility of home-based training. Greater ease of supervising multiple participants at the same time. However, clinical trial data on resistance bands training are limited.
DARE-Bands trial: Main research questions To compare the effects of 24 weeks of Aerobic training only Aerobic training plus resistance bands training on strength, hemoglobin A1c (A1C), and other outcomes, in men and women aged > 35 years with type 2 diabetes. Supported by the Lawson Foundation
DARE-Bands study: other outcomes BMI, waist and hip circumferences Lipids Blood pressure Quality of life: SF-36, EuroQOL EQ-5D-5L, Diabetes Distress Scale Changes in medications Satisfaction with the exercise program
Aerobic training Same in both groups. All participants have an exercise program. Progress to 150 minutes/week of walking. Activity monitored by downloadable MyWellness Key accelerometers (Technogym, Cesena Italy).
Resistance Band Training (RBT) 12 resistance bands exercises. Photographs and YouTube videos of each exercise are available. Use of 8 progressive colour-coded resistance bands, in combination when necessary, to achieve required intensity. Training 3 times per week
Resistance Bands Training (continued) Gradual increase in intensity (colour of band, multiple bands when necessary) and volume (number of sets) Group sessions weekly in weeks 1-4, every 2 weeks in weeks 5-8, every 2-4 weeks thereafter.
Who qualifies? Type 2 diabetes, age 35-75. Not taking insulin. Not already exercising 150 minutes or more per week. No recent resistance exercise training.
Are you potentially interested in participating in the DARE-Bands trial? Samantha McGinley, MSc, Research Coordinator. exercise@ucalgary.ca 403-955-8117