Diabetes is the seventh leading cause of mortality and one of the leading causes of
morbidity in the United States.
86
In 1999, the Centers for Disease Control and Prevention estimated that there were
10.3 million cases and an additional 5.4 million persons in the general population
with undiagnosed diabetes.
National Center for Health Statistics: Vital Statistics of the United States, 1990, Vol. 2, Mortality, Part A, 1994 Hyattsville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, DHHS Publication No. (PHS) 95–1102
20
,
43
Diabetes accounts for at least 10% of all acute hospital days, and in 1992 accounted
for an estimated $92 billion in direct and indirect medical costs.
100
More than 169,000 deaths in the United States per year are attributed to diabetes.
86
This death rate, however, is an underestimate, as in 1993 over 300,000 deaths occurred
among those with diabetes listed as a secondary diagnosis on the death certificate.
National Center for Health Statistics: Vital Statistics of the United States, 1990, Vol. 2, Mortality, Part A, 1994 Hyattsville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, DHHS Publication No. (PHS) 95–1102
115
Many of these deaths were the result of complications of diabetes, particularly cardiovascular
diseases including coronary heart disease (CHD), stroke, peripheral vascular disease,
and congestive heart failure.Diabetes has recently reached epidemic proportions in many developing countries. In
1994, the number of individuals with type 2 diabetes mellitus, which accounts for
90% to 95% of all cases,
43
was about 100 million worldwide. The estimate for the year 2010 is 216 million.
81
,
116
Consequently, in this millennium, type 2 diabetes mellitus will be one of the most
challenging health problems worldwide.
30
Risk factors for type 2 diabetes include older age,
31
,
93
obesity,
55
family history of diabetes,
87
nonwhite ethnicity,
64
and inactivity.
14
,
46
,
50
,
76
,
75
Of these, obesity and physical inactivity are modifiable factors that are amenable
to exercise. Physical inactivity has been identified as a major determinant of type
2 diabetes, and increased activity has been shown to improve insulin sensitivity and
glycemic control among nondiabetic individuals, as well as those with impaired glucose
tolerance or overt type 2 diabetes. According to the American Diabetes Association,
the increasing sedentary way of life, number of older Americans, and greater prevalence
of obesity will elevate the prevalence of type 2 diabetes to epidemic proportions.The diagnosis of diabetes mellitus is based on either two fasting blood glucoses ≥126
mg/dL (7 mmol/L) or a random glucose ≥200 mg/dL (11.1 mmol/L) in the setting of symptoms.
3
,
5
,
79
Glucose tolerance tests are not recommended, except in the setting of pregnancy,
because of the amount of time and effort as well as the variability in results.
34
Diabetes is classified according to etiology (Table 1). Type 1 diabetes is an autoimmune disease resulting in islet cell destruction and
insulin deficiency. Type 2 diabetes has a stronger genetic component involving a combination
of insulin resistance and impaired insulin secretion.
7
,
34
These two defects are most readily expressed in the setting of obesity resulting
from unhealthy diet and sedentary lifestyles.
7
,
34
While youth used to be synonymous with type 1 diabetes, the increasing rates of obesity
(especially among minority populations) have made type 2 diabetes a significant cause
of pediatric hyperglycemia. Gestational diabetes is also a problem related to insulin
resistance and poor secretion; it occurs during the second half of pregnancy due to
the counterinsulin effects of pregnancy-related hormones such as human placental lactogen.
7
Secondary forms of diabetes can result from other conditions often related to other
counterinsulin hormones.
7
,
34
The underlying processes affect the ways in which exercise affects blood glucose
concentrations.Treatment options for diabetes depend, in part, on the type of diabetes. All patients
should be counseled regarding healthy nutrition behaviors. However, diet recommendations
are not the same for these conditions
4
,
49
,
114
; type 2 patients (90% of whom are overweight) should generally be advised on weight
loss, while type 1 patients need to coincide timing of meals with insulin.The pharmacological approach to treating diabetes has changed dramatically over the
past few years. While type 1 patients can only be treated with insulin, there are
now five different types of insulin preparations available (Table 2). In addition, continuous subcutaneous insulin infusion (CSII) or insulin pump therapy
has become increasingly popular, especially among younger, active patients.
Type 2 patients now have five classes of oral agents to consider as well as combining
insulin with oral agent regimens (Table 3). In addition, type 2 patients who cannot take oral agents or who do not achieve adequate
glycemic control with oral agents alone can be treated with split-mixed insulin regimens.
Women with gestational diabetes are typically treated with diet or insulin, although
a recent report suggests sulfonylureas can be used.
72
Sulfonylureas, insulin secretagogues, and insulin itself all raise circulating insulin
levels. Biguanides and thiazolidinediones increase sensitivity to endogenous insulin.
Glucosidase inhibitors decrease postmeal elevations in blood glucose.Exercise has both acute and chronic influences on patients with diabetes. Rapid changes
in glucose concentrations can occur during and following exercise. Before even routine
exercise is recommended to patients, an understanding of acute changes in glucose
production and uptake is important. Following a review of physiological changes due
to exercise, the long-term risks and benefits of exercise are discussed. While exercise
may play a cost-effective role in potentially preventing cardiovascular complications
or even delaying onset of type 2 diabetes, it may exacerbate complications or may
produce consequences due to existing complications.
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Article info
Footnotes
Address reprint requests to Stuart R. Chipkin, MD, Division of Endocrinology, Diabetes and Metabolism, Baystate Medical Center, 759 Chestnut Street, Room S2620, Springfield, MA 01199, e-mail: stuart.chipkin@bhs.org
Identification
Copyright
© 2001 W. B. Saunders Company. Published by Elsevier Inc. All rights reserved.
