expert tips for prescribing physical activity · 2019-03-20 · 1 expert tips for prescribing...

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Expert Tips For Prescribing Physical Activity

Gary Scheiner MS, CDE2014 AADE Diabetes Educator of the Year

Owner & Clinical Director,Integrated Diabetes Services LLC333 E. Lancaster Ave., Suite 204Wynnewood, PA 19096(877) [email protected]

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Objectives

• Describe the essential role physical activity plays in diabetes management

• Apply strategies to minimize risks associated with physical activity in people with diabetes

• Provide the tools necessary to design individualized physical activity plans for people with diabetes

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Amazing Medicine

Diabetes Concern Physical Activity Effect

Heart Disease Collateral Circulation ⇣ Atherosclerosis

Blood Lipids ⇣ LDL, Triglycerides ⇡ HDL

Hypertension ⇣ Diastolic BP

Obesity Calorie Burning

⇡ Metabolism

Appetite Suppression

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Amazing Medicine


Disuse Syndrome Conditioning Gains

Adhesive Capsulitis Flexibility/Range of Motion Work Capacity

Stress Tension Release

More Restful Sleep

Depression Sense of Control, Pride

Pain Endorphin Production

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Amazing Medicine


Insulin Resistance ⇡ Insulin Sensitivity Receptor Proliferation GLUT-4 Transport

Postprandial

Hyperglycemia

Slower CHO Absorption ⇡ Glucose Utilization Accelerated Insulin Action

Need for

Insulin/Meds

Acute and Chronic

Reduction

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✓ CRITICAL to diabetes care & overall Health

Physical Activity:

✓ Comes with certain risks

✓ Requires individualization

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A. 20%

B. 10%

C. 5%

D. <1%

Polling QuestionWhat percentage of diabetes clinics have a physical activity specialist on staff?

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Percent Diabetes Educatorsby Discipline

■ Nurses

■ All other

■ Pharmacists

■ Dietitians

■ Ex. Specialists (0.5%)

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What Is a Physical Activity Prescription?

• Detailed, specific plan of action

• Enhances safety

• Improves outcomes

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• Randomized

• Controlled

• Multi-center

• Blinded analysis

Effectiveness of Physical Activity Advice and Prescription by Physicians in Primary Care

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Grandes, et al. Arch Intern Med 2009; 169(7): 694-701


Control Advice-Only Advice + Prescription

• Provider training

• Standard care

• Provider training

• Used web software re:

benefits, risks, general

activity suggestions

• Summary pamphlet

• Same as advice group, +

• Goal setting

• Barriers addressed

• 3-month Plan

• Printed exercise prescription

(mode, freq., duration, intensity,

progression)

• Self-monitoring log

N=2069

MDs=2

N=1565

MDs=29

N=683

MDs=29

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Incr. in moderate / vigorous activity

(min/week)

Incr. in moderate / vigorous activity

(MET h/week)

Control 31.3 2.05

Advice Only 36.4 2.41

Advice +

Prescription79.7* 5.49*

*p<.01

6 Month Outcomes


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• 681 adult patients

• 10 UK primary care practices

• Randomized

• 3-Year follow-up

Physical Activity Levels in Adults 3-4 years after Pedometer-Based Walking Interventions

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3 Study Arms

Harris T, et al. PLoS Med 2018; 15(3): e1002526

Control “Postal” Program “Nurse Advice” Program

• Pedometer

• Logbook

• Pedometer

• Logbook

• Mailed advice on pedometer

use, increasing physical

activity

• Pedometer

• Logbook

• Training on pedometer use

• Individual strategies for increasing

physical activity

3 year follow-up

vs control:

+ 627 steps/day (p=.004) + 670 steps/day

(p=.002)

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A. True

B. False

Polling QuestionThe physical activity recommendations for people with diabetes are very similar to those without diabetes.

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Designing a Physical Activity Prescription for People with Diabetes

✓Mode/type

✓ Duration

✓ Intensity

✓ Frequency*

✓ Progression

✓ Timing*

✓ Adjustments*

✓Motivation

* Differences!!!

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“Exercise” vs

✓ Uses large muscle groups

✓ Rhythmic or continuous

✓Over a period of time

✓ At least somewhat challenging

Work/Leisure Activity

✓ Tends to be “stop & go”

✓ Intensity may be very low or very high

✓ Duration varies

✓May not be very challenging

✓ Still benefits!

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Physical Activity Prescription

Mode

➢ Large muscle groups

➢ Continuous or rhythmic

➢ Low-impact (if high risk of injury)

➢ Cross train to prevent overuse injuries/burnout

Examples:

✓ Brisk Walking

✓ Cycling

✓ Swimming

✓ Rowing

✓ Stair climbing/EFX

✓ Aerobics classes/videos

✓ Court sports

✓ Strength training

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• Metabolism ⇡

• Insulin sensitivity/glucose disposal ⇡

• Immediate caloric expenditure

• Improve/maintain functional capacity

• Self-image, confidence

Strength Training Benefits

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• Warm-Up first

• 2-3 sets of 10-15 reps

• Work large muscle groups first

• Exhale w/exertion; no valsalva

• Progress reps, then ⇡ weight in small increments

• Only ⇡ weight if technique is sound

• Allow 48 hour recovery

Strength Training Principles

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➢ 20-60 minutes generally recommended

➢ Long duration preferred for weight loss

➢May be broken into a few shorter sessions (for weight loss)

➢ Include 2-5 minute warm-up/cool-down

➢ Stretch after workout (after warmup if high-impact sport)

Physical Activity PrescriptionDuration

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➢ 55% - 90% of predicted maximal heart rate (use actual maximal heart rate if stress tested)

➢ Rating of Perceived Exertion (RPE) of “fairly light” (beginners) to “hard” (experienced /conditioned)

➢ Able to talk, but not sing

Physical Activity PrescriptionIntensity

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1. Nothing

2. Very, Very Light

3. Very Light

4. Fairly Light

5. Somewhat Hard

6. Hard

7. Very Hard

8. Very, Very Hard

9. Painful; Can’t Keep Up

Rating of Perceived Exertion (RPE)

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➢ Think of physical activity as medicine

➢ Enhanced insulin sensitivity decays, lost completely after 24-72 hours

➢ Be active most (if not all) days of the week

➢ Do not skip more than one day

Physical Activity PrescriptionFrequency

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Activity Levels Affect Insulin Sensitivity PROFOUNDLY

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

M Tu W Th F Sa Su

Insu

lin S

en

sitiv

ity

daily

2-3 x/wk

never

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➢ Set up to succeed!

➢ Beginners: start with low intensity, short duration

➢ Build duration first, then increase intensity

➢ Add new activities as conditioning permits

Physical Activity PrescriptionProgression

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➢Wk 1: 9 min light, 1 min hard (x3=30 min)




➢ Etc …

Progression throughInterval Training

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➢ After meals (if taking mealtime insulin and weight loss desired)

➢ After meals (to improve postprandial BG control)

➢ Pre-meal (with unstable CAD, CHF)

➢Morning (for long-term maintenance)

➢ Anytime it is convenient and preferred

Physical Activity PrescriptionTiming

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➢ Hypoglycemia Prevention

➢ Hyperglycemia Prevention

Physical Activity PrescriptionAdjustments

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• Premixed/Day NPH Users

• MDI/Pump Users

• Basal Insulin (Only) Users

• Meglitinide Users

• Sulfonylurea Users (especially glyburide)

• Combination Med Users

Who Is At Risk for Hypoglycemia?

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Hypoglycemia Prevention Based on Timing and Duration


Activity Within 2 Hours

after Meal

Activity Before or

Between Meals

Short Duration

(<90 Minutes)Mealtime insulin/OHA Snack prior to activity

Long Duration

(>90 Minutes)

Mealtime insulin/OHA

Basal Insulin

Snack hourly

Watch for delayed-onset hypo

Snack prior to activity

Basal insulin

Snack hourly

Watch for delayed-onset hypo

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Mealtime Med Adjustmentsfor Post-Meal Activity

➢ Low intensity cardio: ⇣ insulin bolus 25%

➢Mod. intensity cardio: ⇣ insulin bolus 33%

➢ High intensity cardio: ⇣ insulin bolus 50%

➢ Skip meglitinide

➢ Skip or reduce sulfonylurea

➢ Skip pramlintide

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Snacking to Prevent Hypoglycemiafor Pre/Between Meal Activity

Glucose Burned Per 60 Minutes of Physical Activity

50 lbs (23 kg) 100 lbs (45 kg) 150 lbs (68 kg) 200 lbs (91 kg) 250 lbs (114kg)

Low Intensity 5-8g 10-16g 15-25g 20-32g 25-40g

Mod. Intensity 10-13g 20-26g 30-40g 40-52g 50-65g

High Intensity 5-18g 30-36g 45-55g 60-72g 75-90g

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Can Physical Activity Cause Glucose to Rise?

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Adrenaline Raises Glucose!

⇣ Muscle activity

⇣ Insulin

⇣ Diabetes meds

⇣ Glycosuria

⇡ Carbohydrate

⇡ Protein (in absence of CHO)

⇡ Dehydration

⇡ Counterregulatory hormones

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✓ Adequate hydration

✓ Avoid extreme high intensity activity

✓ Keep “mental intensity” to a minimum

✓ Use preemptive insulin if predictable rise

✓ Reasonable carb intake

✓Minimize extended pump disconnection

Preventing Rise in Glucose

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No Such Number

✓ Performance may suffer

✓ Hydrate

✓ Administer Rapid-Acting Insulin

The Exception: Ketosis

How High is too High?

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with Exercise

✓ Check blood (or urine) for ketones with unexplained high BG

✓ No exercise with positive ketones

✓ OK to exercise if nonketotic – take 50% of usual correction bolus and drink plenty of water

To Prevent Ketosis/DKA

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Physical Activity PrescriptionMotivation

➢Motivation through information

➢Motivation through inspiration

➢Motivation through implementation

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Motivation through Information

➢ Describe the pathophysiology

➢ Explain the benefits

➢ Focus on issues pertinent to the patient

• Weight loss?

• Appearance?

• Performance?

• Stopping/staying off meds?

• Reducing blood sugar?

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Motivation through Inspiration

➢ Personal follow-up (call/letter/e-mail)

➢ Create a “wall of fame” in the office

➢Offer token incentives (water bottles, shirts, hats)

➢Write/sign a contract

• Network your patients (clubs, group events)

• Issue a challenge to an individual or group

• Lead by example. Be active yourself! Share your experiences.

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➢ Provide a specific action plan

➢ Choose fun modes of activity

➢ Avoid injuries (variety, warm-up, proper shoes, low impact)

➢Manage the meds to prevent hypos, facilitate weight loss

Motivation through Implementation

• Take on responsibility (complete activity while doing things for others or for a job)

• Accomplish 2 things at once (TV, music, phone, read, time with friends)

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Implementation Insights

Most Women Prefer:

✓ Activities with others

✓ Supervision/instruction

✓ Scheduled sessions

✓ Low-moderate intensity

Most Men Prefer:

✓ Individual activities

✓Moderate-high intensity

✓ Spontaneity/flexibility

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Implementation Insights

Most Younger People Prefer:

✓ Counseling from an exercise specialist

✓ Evening activity

✓Moderate-high intensity

Most Older People Prefer:

✓Morning activity

✓ Low-moderate intensity

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Time for YOU to Be the Physical Activity Specialist!

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• 55 Year old female, 280 lbs (150 kg)

• Lives in inner-city; works at mall as a cashier. Also tends to 4 grandkids

• Type 2 diabetes x 5 years; taking maximum dose of glyburide, metformin and sitagliptin. PCP “threatened” insulin if she does not lose weight.

• BG usually 180-200 fasting. History of hypoglycemic symptoms with delayed meals.

• Has an old stationary bike, uses it to hang/dry clothes

• Social butterfly

Betty Bloodsugar

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expert tips for prescribing physical activity · 2019-03-20 · 1 expert tips for prescribing...

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