Diabetes Mellitus and Physical Therapy
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1. Diabetes mellitus is a condition where the body does not properly process glucose due to problems with insulin production or insulin resistance. There are four main types of diabetes: type 1, type 2, gestational diabetes, and pre-diabetes. 2. Exercise can help manage blood glucose levels and improve health for most people with diabetes, but some with more severe cases may see worsening of symptoms. Proper diet and rest is important for those individuals. 3. Genetics and lifestyle factors both contribute to type 1 and type 2 diabetes. While genes influence risk, environment like diet, physical activity levels, and weight play a major role in the development and management of diabetes.
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Diabetes Mellitus and Physical Therapy
- 2. “..In some people suffering from this affliction, exercise can improve the condition and should be done regularly. In more extreme cases its effects worsen the condition. These people should rest until the condition improves….” -SUSHRUTA , 600 BC
- 6. TYPES OF DIABETES MELLITUS 1.Type 1 diabetes : results from the body’s failure to produce insulin. Between 5% and 10% of Americans diagnosed with diabetes have the type 1 subgroup. 2. Type 2 diabetes : refers to a relative insulin deficiency that results in hyperglycemia. Approximately 90% to 95% of Americans diagnosed with diabetes exhibit insulin resistance. 3. Gestational diabetes : affects about 4% of all pregnant women or about 135,000 cases in the United States each year. 4. Pre-diabetes : occurs when a person’s blood glucose reaches higher-than-normal levels but not high enough for diagnosis as type 2 diabetes.
- 7. DIABETES : SIGNS & SYMPTOMS Twelve diabetes signs and symptoms include: 1. Elevated blood glucose (hyperglycemia) 2. Frequent urination (polyuria) 3. Excessive thirst (polydipsia) 4. Extreme hunger (polyphagia) 5. High levels of blood ketones from reliance on excessive fat catabolism 6. Unexplained weight loss 7. Increased fatigue 8. Irritability 9. Blurry vision 10. Numbness or tingling in the extremities (hands, feet) 11. Slow-healing wounds or sores 12. Abnormally high frequency of infection
- 8. DIABETES…. IN OUR GENES & LIFESTYLE..!!?? Most type 1 diabetics inherit risk factors from both parents, with inherited traits more common in whites than blacks or Asians. The most prominent “environmental triggers” include cold weather exposure (develops more often in winter than summer and more frequently in places with cold climates), viral infection, and early diet (less common in those who were breastfed and in those who first ate solid foods at a later age). Type 2 diabetes has a stronger genetic basis than type 1, yet its occurrence also depends more on environmental factors. The disease most likely results from the interaction of genes and lifestyle factors, including physical inactivity, weight gain (>80% of type 2 diabetics are obese), aging, and possibly a high-fat diet.
- 9. ….ITS ALL ABOUT THE BEST USE OF MUSCLES…. A dysregulation in glycolytic and oxidative capacities of skeletal muscle relates to insulin resistance in type 2 diabetes . Experts estimate that up to 92% of type 2 diabetes can be changed by diet and lifestyle. Use the following Internet site to calculate your diabetes risk: www.diabetes.org/risk-test.jsp.
- 10. WHY PEOPLE WITH DIABETES EXERCISE??... Exercise generally lowers blood glucose resulting in decreased insulin or OHA requirements. CVD risk factors are potentially improved by regular exercise. Exercise may prevent or delay the progression of diabetes related complications. Exercise improves general health.
- 11. • To survive, people in early times had to have genes that permitted the body to store fuel in times of excess so that they would have a source of energy during times of famine. • These genes that permit efficient food storage are termed, “Thrifty Genes”. They cause rapid weight gain in times of abundant food supply. • The advantage of this trait is that the bearer is much more likely to survive in the absence of food.
- 12. …THUS..PEOPLE NEED TO BE PHYSICALLY ACTIVE… The problem is that in a society where food is always plentiful and physical activity is not a part of the lifestyle, thrifty genes cause obesity, diabetes and related problems. In the absence of the need to hunt and gather and with food always available we need to make an effort to incorporate physical activity in our lives.
- 13. ……. BECAUSE OF THE HUMAN GENOME , IT IS NECESSARY TO RE-INTRODUCE PHYSICAL ACTIVITY IN OUR ROUTINE….
- 14. REGULATION OF GLUCOSE FLUXES DURING EXERCISE...
- 24. PROPOSED MEACHANISM BY WHICH ACUTE EXERCISE ENHANCES INSULIN SENSITIVITY • Increased muscle blood flow • Increased capillary surface area • Direct effect on working muscles • Indirect effect mediated by insulin-induced suppression of FFA levels
- 26. CVD RISK FACTORS ARE POTENTIALLY IMPROVED BY REGULAR EXERCISE • Glucose Intolerance • Hyper-insulinemia • Hyperlipidemia • Coagulation Abnormalities • Hypertension • Obesity
- 27. EXERCISE INDUCED HYPOGYCEMIA • While exercise-induced hypoglycemia is generally not common in non-insulin dependent diabetes, it is extremely prevalent in insulin dependent diabetes. • Hypoglycemia may occur during exercise or after exercise (even up to 24 h following the cessation of an exercise session). • Hypoglycemia can be prevented by eating more, taking less insulin, or both.
- 28. GENERAL CONSIDERATIONS IN DIABETIC PEOPLE PRIOR TO EXERCISE PRESCRIPTION • Physical screening prior to starting an exercise program • Metabolic control • Blood glucose monitoring • Food intake • Insulin administration (when applicable) • Make physical activity compatible with a person's lifestyle and interests
- 29. THE CONCEPT OF OBLA..
- 30. • If blood glucose <5 mM extra calories before exercise likely required. • If blood glucose 5-12 mM extra calories probably not required. • If blood glucose >12 mM measure urine ketones. • If urine ketones negative, exercise can be performed and extra calories not required. • If urine ketones positive, take insulin and delay exercise until ketones negative.
- 32. • A source of CHO should be readily available during and after exercise. • Consume CHO as needed to avoid hypoglycemia. • Consume proteins & fats for prolonged exercise in order to prevent post-exercise hypoglycemia.
- 33. THE 3 MOST IMPORTANT FACTORS IN DETERIMING THE SUCCESS OF ANY EXERCISE PROGRAM ARE…
- 34. “Those who think they have no time to exercise will have to find time for illness..” - Edward Stanley,Earl of Derby (1826-1893)
Editor's Notes
- The affliction he referred to was diabetes. The role of exercise in diabetes management expressed by Sushruta was essentially the prevailing sentiment for 2500 years. This all changed dramatically in 1921. A 14 year old boy, Leonard Thompson, was successfully treated with insulin by Frederick Banting in Toronto, Ontario. This changed the lives of people with diabetes forever. It also changed the way that exercise and its relationship to diabetes was viewed in two markedly different ways. First, although exercise and insulin were now viewed as cornerstones of diabetes therapy the two together could result in potentially dangerous hypoglycemia, a condition rarely seen in these people before 1921. Exercise-induced hypoglycemia now becomes a concern. The second way that the perception of exercise in diabetes changed was that people with diabetes were now living longer. Diabetic complications, such as heart disease and atherosclerosis, become a serious concern. There is now a reason for people with diabetes to be fit. Exercise should be advocated so as to keep risk factors for cardiovascular disease, which are particularly prevalent in people with diabetes, from manifesting themselves.
- The interaction between glucose and insulin serves as a feedback mechanism to maintain blood glucose concentration within narrow limits. Rising levels of plasma amino acids also increase insulin secretion.
- A decline in plasma glucose concentration below 100 mgdl stimulates the alpha cells’ release of glucagon, resulting in a nearinstantaneous glucose release from the liver. Glucagon contributes to blood glucose regulation during endurance exercise and starvation. Interestingly, plasma amino acids also stimulate glucagon release. This pathway prevents hypoglycemia after a person ingests a pure protein meal. If a meal contains protein without carbohydrate, amino acids in the food trigger insulin secretion. Even though no glucose has been absorbed, insulin-stimulated glucose uptake increases, and plasma glucose concentration decreases. Co-secretion of glucagon in this situation prevents hypoglycemia by stimulating hepatic glucose output. With amino acid ingestion, both glucose and amino acids become available to peripheral tissues.
- Clinicians have discontinued the former use of the terms insulin-dependent diabetes mellitus (IDDM; type 1) and noninsulin-dependent diabetes mellitus (NIDDM; type 2) because these diseases often require treatments that overlap and vary rather than reflect the underlying pathogenesis.
- The lifestyle factors contribute to the 70% increase in the disorder among persons in their 30s during the last decade of the 20th century and a 33% overall increase nationally.
- There is good reason to believe that regular physical activity is a good thing. The metabolic demands posed by each individual exercise bout presents challenges to the body. In response to exercise, there is an increase in the mobilization of fuels and an increase in the availability of these fuels to the muscles. FFA are mobilized from fat cells where it supplies energy for working muscle and drives gluconeogenesis at the liver. Amino acids are mobilized from the GI tract. Glucose is mobilized from the liver and utilized by working muscle. The feature that makes glucose unique is that in healthy individuals glucose is usually regulated within narrow limits. I would like to focus on the process of glucoregulation during exercise.
- This scheme illustrates the sites at which skeletal muscle glucose uptake can be regulated. Glucose moves from capillaries to sarcolemma in the cell and is then phosphorylated in the cell. The gears are used to illustrate the close coupling of glucose flux in these three sites. Below each gear are potential mechanisms of regulation.
- One remarkable aspect of the response to exercise is that it also leads to an increase in glucose tolerance and insulin action that is sustained well into the post exercise state. This is particularly important to people with diabetes, because failure to adjust diet or therapy can lead to post-exercise hypoglycemia.
- In addition, to an improvement in these risk factors for CV disease. Regular physical activity leads to many adaptations that are consistent with improved cardiovascular function (increased capillarization of skeletal and heart muscle, improved stroke volume, greater myocardial mass).