Managing the Medicine of Choice: Physical Activity & Diabetes

1. Managing the Medicine of Choice: Physical Activity & Diabetes Virginia Kay Mirenzi, MS, RD, CDE, LDN, HFS

2. Physical Activity & Diabetes Identify resources for assessing current level and starting a physical activity plan Discuss effective methods of motivating and monitoring change in physical activity with diabetes Discuss key strategies in managing glucose control & physical activity

3. Benefits of Physical Activity in DM • Increased insulin sensitivity • Reduced risk of CVD, HTN, obesity • Increased life expectancy • Increased aerobic endurance, muscle fitness, flexibility & balance • Lower A1C • Enhanced self-esteem and sense of well being

4. Active American Adults • 58% of adults without Diabetes are physically active • 39% of adults with Diabetes are physically active

5. Exercise is Medicine • http://exerciseismedicine.org • “Calling on all health care providers to assess & review every patient’s physical activity program at every visit.”

6. Pre-exercise Evaluation • Risks • Hyperglycemia • Hypoglycemia • Musculoskeletal injury • Cardiovascular accident (angina, MI, dysrhythmia, sudden death) • Deterioration of underlying retinopathy and nephropathy • Safe exercise can be complicated by presence of DM related complications: • CVD • HTN • Neuropahty • Microvascular changes

7. Assessment for Physical Activity • Clinical history & Labs • Exercise & Weight history • Assess barriers to PA • Physician evaluation • Podiatrist & Ophthalmologist checks • Exercise Testing • ECG vs. Exercise Stress Test

8. Participant Evaluations • Physical Activity Readiness Questionnaire (PAR-Q) • The AHA/ACSM Health/Fitness Facility Pre-participation Screening Questionnaire

9. Low intensity PA • Use clinical judgment • No evidence pre-exercise testing necessary, as CVD diagnostic tool, may be barrier • Walking or indoor cycle at low intensities great starting PA

10. Beauty of a Brisk Walk • 50% of VO2max • Muscles using 50% fat & 50% glucose: burns fat, lowers BG • Physically safe • Good CV fitness • Talk while exercise!

11. Evaluation before PA • Anything more intense than brisk walking: physician evaluation • ECG exercise stress testing • Age > 40 yr • Age > 30 yr with DM > 10 yrs or • HTN, Smoking, dyslipidemia, retinopathy, nephropathy • CAD or PAD • Autonomic neuropathy • Advanced nephropathy

12. Using Evaluation to ID current PA capacity & progression • Stress Testing : Target Heart Rate range & Intensity • Podiatry Exam: Type/ Mode • Ophthalmology Eval: Type /Mode • Kidney labs: Type/Mode • Enlist Experts for Exercise Prescription / Partner with Trainers

13. ACSM www.acsm.org • Market place • Current Fact Sheets • Roundtables • Position Statements • Journal Articles

14. 5 Stages of Physical Activity • Couch Potato“I am inactive & I plan to stay that way.” • Inactive Thinker“I am inactive but I am thinking about becoming active.” • Planner “I am taking steps to start to be active.” • Activator“I am active but not as active as I should be.” • Active Exerciser“I am regularly active and have been for some time.”

15. What stage are you now?

16. Battle of Wills Plato: “We have a rational charioteer who has to rein in the unruly horse that barely yields to horsewhip and goad combined.” • The brain has 2 independent systems at work at all times • Emotional side: instinctive, feels pain and pleasure, language of feelings • Rational side: reflective or conscious system, deliberates and analyzes, looks into the future

17. Elephant: Emotional side Rider: Rational side Jonathan Haidt in Happiness Hypothesis & Chip & Dan Heath inSwitch.

18. To Change Behavior • Direct the Rider: What looks like resistance is often a lack of clarity • Motivate the Elephant: What looks like laziness is often exhaustion • Shape the Path: What looks like a people problem is often a situation problem

19. The struggle between Elephant & Rider • Experiment part #1: Radish vs. Chocolate • Experiment part #2: Solve problem, High School vs. College students

20. Persistence on Unsolvable Puzzles J Per Soc Psy, 1998, 74, 5

21. Change is tiring! • Dozens of studies demonstrate the exhausting nature of self-supervision • Wedding registry • Ordering new computer • Restrain emotions while watching movie • The bigger the change, the bigger the drop in self-control & problem solving afterwards

22. Willpower: Rediscovering our greatest strength by Roy Baumeiser & John Tierney • Marshmallow experiment • Muscle to improve with practice • Uses energy

23. Decision Fatigue = Ego depletion • Brain scans reveal ego depletion with decision making & suppression of wants, increased activity in nucleus accumbens, reward center and less activity in amygdala, which helps with impulse control • In times of heavy decision making and lots of control, food’s appeal is stronger while impulse control weakens • Self-control tasks lower circulating blood sugars and increase craving for sweets • Studies suggest many people spend 3-4 hours a day resisting desires (food, sleep, Facebook, spend $, sex, TV) lowering ability to control self-care behaviors • Recognize the impact on people with DM

24. Direct the Rider • Follow the Bright Spots: Spark the hope • Script the critical moves: Stop decision paralysis • Point to the Destination: Give picture of short term and longer term endpoints

25. Direct the Rider with DM & PA • Follow Bright Spots: Give specific examples of other pts success, Support groups • Script the critical moves: a specific behavior that is within the pts control and abilities, like walk at lunchtime • Point to the Destination: Lower BG, drop a clothes size, lower A1c

26. “Darryl” • 61 yr T2DM • Dx at 40 years old • Obese most of adult life, up and down weight, increasing meds,at 55 yr ,A1c = 8.1

27. “Darryl” at 55 years old • Became an exerciser • Started with 15 minute walk, 3x/wk • Joined Weight Watchers

28. “Darryl” at 61 Active lifestyle: cycles, swims, walks, snow-shoe walking in winter, kayaking • Maintains goal of 60 min 5 x / wk • A1C = 5.5 %, no DM meds • Became Weight Watchers leader

29. Motivate the Elephant • Find the Feeling • Shrink the Change • Appeal to Identity • Grow Your People SEE-FEEL-CHANGE

30. Motivate the Elephant: DM & PA • Find the Feeling: What engages change for person? • Shrink the Change: Reframe • Appeal to Identity: Rename • Grow Your People: Journey

31. Weight Management Group • Grandma training • Wear wedding rings • Vegetable & water contest • Address one habit a month • Work time athletes • Not on a diet, on a Health Journey, not a destination but a path

32. “Debbie” • T2 Dm, dx at 37 yrs • 46 yrs • DM Meds: glipizide ER 10mg. BID, glucophage 1000mg BID • Ht 63.5 in., Wt 273 lbs. • A1c: 11.2% • Endo ready to start insulin therapy

33. “Debbie” • “Debbie the Exerciser” • Chose dancing at home • Record keeping helped see exercise impact • Phone follow-up, next day & 2 wks • 4 wk follow up appt. • Support Group

34. “Debbie” 3 month Follow-up • A1c = 6.5% • Weight decreased 10 lbs, dropped 2 dress sizes • No changes in DM meds, not add insulin at this time • Added walking at lunch & bought some home equipment

35. Shape the Path • Tweak the Environment: Map • Build a Habit: Action Triggers • Rally the Herd: Behavior is contagious

36. Shape the Path: DM & PA • Tweak the Environment: Equipment in the TV room, Sit on exercise ball at work • Build a Habit: Set up Action Triggers, like gym bag in car, walking shoes at work • Rally the Herd: Social network, web sites with support & e-mail, Support Group, Group Fitness

37. Connected Health • Heart Monitors • Striv • Jawbone • FitBit • Basis Band • Nike Fuel Band • Pedometers • Apps • On-line • Myfitnesspal.com • Sparkpeople.com

38. “Donna” • 57 yr • T2DM, dx at 48 yr • DM Meds: Levimir 50 units am, 52 units pm, metformin 500 mg am, 1000 mg pm, Novolog flexpen base 7 units, sliding scale • 61 inches, 217 lbs • No exercise plan • A1C: 8.1%

39. “Donna” • Team approach • Screened and tested for exercise • Personal Trainer: Twice week, Cardio start, and increase to RT and Cardio • RD/CDE: weekly, then monthly, Carb counting, meal timing • Therapist: weekly and then monthly • PCP: every 3 months

40. 2 days with trainer,60 minutes, combo of aerobic & RT 2 days yoga 3 days home cycle with interval training: 5 min Warm, 30 sec.high intensity, 60 sec. moderate, repeat, 9 min currently 5 min Cool Lost 20 pounds A1c = 6.9 %, Levimir:40 units BID Novolog: base of 3 units sliding scale CDE, PCP, Therapist: every 3 months “Donna” 3 month follow-up

41. Pathways of glucose into muscle • Insulin dependent BG uptake into skeletal muscle at rest & post-prandially, impaired in T2DM • During Physical Activity, contractions increase BG uptake to supplement intramuscular glycogenolysis, not impaired by insulin resistance or T2DM

42. Changes in fuel as Exercise • Muscle glycogen provides the fuel • As intensity increases and glycogen stores deplete, increased uptake of circulating BG, with FFA from adipose tissue • Switch from mostly FFA at rest, to blend of fat, glucose & muscle glycogen with PA • Intramuscular lipid stores used during longer duration activities and recovery • As duration increases enhanced gluconeogenesis

43. Acute changes in muscular insulin resistance • Most individuals experience a decrease in BG during mild- moderate intensity activity for 2 – 72 hours • BG reductions related to duration, intensity, pre-exercise control and type training • Acute improvements found at all levels of intensity

44. Aerobic Exercise Effects • Moderate aerobic exercise improves BG and insulin action acutely • Risk of hypoglycemia minimal without use of exogenous insulin or insulin secretoagogues • Brief, intense aerobic exercise raises plasma catecholamin levels • Hyperglycemia can result for 1 – 2hours

45. Effects of Aerobic & RT on A1C levels in patients with T2DM • A randomized Controlled Trial • Among pts with T2DM, a combo of aerobic and RT compared with non-exercisers improved A1C, not achieved by aerobic or RT alone • JAMA Church, et al 2010, Vol 304, no. 20

46. “Daniel” • 49 yr T2DM • Dx at 43 yr, DM education, kept A1c in 6.5 – 7.1 % range until recently, now 8.5% • Eats very low carbs, Ht 73.5 inches, wt- 214 lbs. • Not monitoring BG, no exercise • Metformin ER 750 mg BID, Glimepiride 4 mg. BID • 5 kids, busy Executive

47. Younger Adults: Gain Weight: 30% Lean Mass Lose weight: 30 – 50% Lean Mass Older Adults: Gain Weight: greater% is fat mass Lose weight: usually > 50% Lean Mass Body Composition with Weight Loss

48. Changes in body with less muscle and more fat • Decreased metabolic rate • Decreased Aerobic capacity (VO2max) • Insulin resistance

49. Sarcopenia • Age related loss of skeletal muscle mass • Evans, William. Sarcopenia and age-related changes in body composition and functional capacity, J. Nutr., 123; 465-468, 1993

50. Sarcopenia • Reduced protein reserves • Decreased strength and functional capacity • Reduced aerobic capacity • Reduced energy requirements • Leads to other health issues