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EXERCISE AND DIABETES

  • Stuart R. Chipkin
    Affiliations
    Department of Medicine, Tufts University School of Medicine (SRC, SAK)

    Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst (SRC, LC-T)

    Division of Endocrinology, Diabetes, and Metabolism, Baystate Medical Center (SRC, SAK), Springfield, Massachusetts
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  • Serena A. Klugh
    Affiliations
    Department of Medicine, Tufts University School of Medicine (SRC, SAK)

    Division of Endocrinology, Diabetes, and Metabolism, Baystate Medical Center (SRC, SAK), Springfield, Massachusetts
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  • Lisa Chasan-Taber
    Affiliations
    Department of Biostatistics and Epidemiology, School of Public Health and Health Sciences, University of Massachusetts, Amherst (SRC, LC-T)
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      Diabetes is the seventh leading cause of mortality and one of the leading causes of morbidity in the United States.

      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

      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.

      Centers for Disease Control and Prevention, National Diabetes Fact Sheet: National estimates and general information on diabetes in the United States 1999. Atlanta, Ga., U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, pp 1–8

      Harris MI: Classification, diagnostic criteria, and screening for diabetes. In Diabetes in America, sponsored by the National Diabetes Data Group, 1995. NIH, NIDDK, Publication No. 95-1468, pp 15–36

      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.
      • Rubin K.
      • Schirduan V.
      • Gendreau P.
      • et al.
      Predictors of axial and peripheral bone mineral density in healthy children and adolescents, with special attention to the role of puberty.
      More than 169,000 deaths in the United States per year are attributed to 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

      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.
      • Surgeon General's report on physical activity and health
      Centers for Disease Control and Prevention.
      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,

      Harris MI: Classification, diagnostic criteria, and screening for diabetes. In Diabetes in America, sponsored by the National Diabetes Data Group, 1995. NIH, NIDDK, Publication No. 95-1468, pp 15–36

      was about 100 million worldwide. The estimate for the year 2010 is 216 million.
      • Mayer-Davis E.J.
      • D'Agostine Jr, R.
      • Karter A.J.
      • et al.
      Intensity and amount of physical activity in relation to insulin sensitivity: the Insulin Resistance Atherosclerosis Study.
      • Valle T.
      Tuomilehto J. Eriksson J: Epidemiology of NIDDM in Europids.
      Consequently, in this millennium, type 2 diabetes mellitus will be one of the most challenging health problems worldwide.
      • Eriksson J.G.
      Exercise and the treatment of type 2 diabetes mellitus.
      Risk factors for type 2 diabetes include older age,

      Everthart J. Knowler WC, Bennett PH: Incidence and risk factors for non-insulin-dependent diabetes. In Harris MI, Hamman RF, (eds): Diabetes in America 1985. Washington, D.C., National Diabetes Data Group. U.S. Gov. Printing Office IV. USDHHS, NIH Publication no. 85-1468, pp 1–35

      • Palumbo P.J.
      • Elveback L.R.
      • Chu C.P.
      • et al.
      Diabetes mellitus: incidence, prevalence, survivorship and causes of death in Rochester, Minnesota, 1945–1970.
      obesity,
      • Ivy J.L.
      • Zderic T.W.
      • Fogt D.L.
      Prevention and treatment of non-insulin-dependent diabetes mellitus.
      family history of diabetes,
      • National Diabetes Data Group
      Classification and diagnosis of diabetes and other categories of glucose intolerance.
      nonwhite ethnicity,
      • King H.
      • Rewers M.
      Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults.
      and inactivity.
      • Burchfiel C.M.
      • Sharp D.S.
      • Curb J.D.
      • et al.
      Physical activity and incidence of diabetes: The Honolulu Heart Program.
      • Helmrich S.P.
      • Ragland D.R.
      • Leung P.W.
      • et al.
      Physical activity and reduced occurrence of non-insulin-dependent diabetes mellitus.
      • Hu F.B.
      • Sigal R.J.
      • Rich-Edwards J.W.
      • et al.
      Walking compared with vigorous physical activity and risk of type 2 diabetes in women.
      • Manson J.E.
      • Rimm E.B.
      • Stampfer M.J.
      • et al.
      Physical activity and incidence of non-insulin-dependent diabetes mellitus in women.
      • Manson J.E.
      • Nathan D.M.
      • Krolewski A.S.
      • et al.
      A prospective study of exercise and incidence of diabetes among US male physicians.
      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.
      • American College of Sports Medicine
      Exercise and type 2 diabetes (position stand).
      • American Diabetes Association
      Screening for diabetes (position statement).

      Massachusetts Department of Public Health: Massachusetts Guidelines for Adult Diabetes Care. June 1999

      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.
      • Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
      Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
      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.
      • Bennett P.H.
      Definition, diagnosis, and classification of diabetes mellitus and impaired glucose tolerance.
      • Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
      Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
      These two defects are most readily expressed in the setting of obesity resulting from unhealthy diet and sedentary lifestyles.
      • Bennett P.H.
      Definition, diagnosis, and classification of diabetes mellitus and impaired glucose tolerance.
      • Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
      Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
      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.
      • Bennett P.H.
      Definition, diagnosis, and classification of diabetes mellitus and impaired glucose tolerance.
      Secondary forms of diabetes can result from other conditions often related to other counterinsulin hormones.
      • Bennett P.H.
      Definition, diagnosis, and classification of diabetes mellitus and impaired glucose tolerance.
      • Expert Committee on the Diagnosis and Classification of Diabetes Mellitus
      Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
      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
      • American Diabetes Association
      Diabetes mellitus and exercise (position statement).
      • Horton E.S.
      Exercise.
      • Spelsberg A.
      • Manson J.E.
      Physical activity in the treatment and prevention of diabetes.
      ; 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.
      • Langer O.
      • Conway D.L.
      • Berkus M.D.
      • et al.
      A comparison of glyburide and insulin in women with gestational diabetes mellitus.
      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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