Exercise training for patients with Type 2 diabetes and cardiovascular disease
Wednesday, February 20, 2019
The World Health Organization estimated that 9 percent of the world's population had diabetes in 2014, and over 90 percent of these suffered from Type 2 diabetes. Moreover, Type 2 diabetes already causes 5 million deaths per year, mostly from cardiovascular diseases, and Type 2 diabetes is expected to become the seventh-leading cause of death globally by 2030.
Obesity is the major potentially modifiable risk factor for Type 2 diabetes, with an exponential relationship between Body Mass Index and the risk of Type 2 diabetes. Visceral adiposity explains the increased risk in men, who have a more central adipose tissue distribution, compared to women at similar BMI, which reflects metabolically unfavorable lifestyle factors such as excessive calorie intake in relation to reduced physical activity.
According to a recent position paper, patients with Type 2 diabetes should be prescribed physical activity to control blood sugar and improve heart health. According to Dr. Hareld Kemps, a cardiologist at Máxima Medical Centre in Veldhoven, Netherlands, diabetes doubles the risk of mortality, but the fitter patients become, the more that risk declines. Unfortunately, most patients do not engage in exercise programs. Kemps recommends the following:
Patients should see their doctors for a personalized plan, adapting plans to patient preference, and those with health insurance should ask if exercise programs are covered. Remote guidance is growing in popularity; patients monitor themselves with smartwatches and then send data to a health professional for feedback.
Patients need to set specific motivational goals. For elderly patients, this could be climbing the stairs in their homes or walking to the supermarket — achievements that will really improve their quality of life.
Clinical targets should include cardiorespiratory fitness and glycemic control, both improving with exercise training. These changes can be measured, and they are directly related to well-being, morbidity and mortality as well, helping to lower blood pressure and harmful blood lipids. Although weight loss is important, it is not the best target for exercise training alone. Exercise needs to be part of a multidisciplinary intervention that includes nutrition.
The type and intensity of exercise should be personalized to each patient. High-intensity interval training, alternating moderate and vigorous walking, is most effective at boosting fitness and controlling blood sugar but may be unsafe for patients who develop arrhythmias during exercise or who have ischemia.
According to Kemp, even small increases in activity can benefit patients with Type 2 diabetes and heart problems. Interrupting sitting with brief bouts of walking improves glucose control, while two hours of brisk walking per week reduces the risk of further heart problems.
Just advising patients to exercise, which is what doctors typically do, is not enough. Patients must be assessed for comorbidities, risks related to exercise, and personal preferences. Policy makers and healthcare insurers will need to be aware that these recommendations will be cost effective in the long run. And clinicians need to call for programs to be reimbursed.
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