1nL LIILC1S CI DIIILkLN1

LkLkCISL IN1LkVLN1ICNS CN
GLCLMIC CCN1kCL IN 1L 2
DIA8L1LS MLLLI1US
A|||e Matarasso
Apr|| 20, 2012
1nL 12DM LIDLMIC
! 1he g|oba| preva|ence of 12DM connnues to
|ncrease rap|d|y
! 12DM-re|ated comp||canons account for
10-1S of hea|th care costs |n deve|oped
countr|es (nansen et a|., 2010, Sanz et a|., 2010)
MANAGLMLN1 CI 12DM
! r|mary Goa|: Improve g|ycem|c contro| |n
order to prevent chron|c hyperg|ycem|a
! Ind|cated by reducnons |n hemog|ob|n A1c
(nbA1c) va|ues
! A reasonab|e nbA1c for many non-pregnant
adu|ts |f < 7 (Amer|can D|abetes Assoc|anon, 2011)
LkLkCISL IN DIA8L1LS 1nLkA
! Considered to be a cornerstone of diabetes
therapy
! Increases insulin sensitivity and blood glucose
uptake by creating a metabolic demand on
skeletal muscle (Hills et al., 2009)
! Increased blood glucose uptake into skeletal
muscle leads to reductions in blood glucose
levels
1LS CI LkLkCISL
! Aerob|c 1ra|n|ng (A1)
! kes|stance 1ra|n|ng (k1)
! Comb|nanon 1ra|n|ng (C1)
ALkC8IC 1kAINING (A1)
! 1ra|n|ng that |nvo|ves the connnuous,
repennve movement of |arge musc|e groups
! 1rad|nona||y recommended for |nd|v|dua|s
w|th 12DM (n|||s et a|., 2009)
! Increases |nsu||n sens|nv|ty as we|| as:
- Improves card|ovascu|ar htness
- keduces card|ovascu|ar r|sk factors
- romotes we|ght |oss
kLSIS1ANCL 1kAINING (k1)
! A|so known as "strength tra|n|ng"
! 1ra|n|ng that prov|des an externa| force on
the musc|e
! More recent|y recommended for |nd|v|dua|s
w|th 12DM (n|||s et a|., 2009)
! Increases |nsu||n sens|nv|ty as we|| as:
- Increases musc|e strength and
endurance
- Increases energy expend|ture
- Decreases body fat percentage
CCM8INA1ICN 1kAINING (C1)
! 1ra|n|ng that |ncorporates both A1 and k1
components
! 8enehts |nc|ude |ncreases |n |nsu||n
sens|nv|ty as we|| as the benehts from A1
and k1
CURRENT EXERCISE
RECOMMENDATIONS FOR T2DM
PATIENTS
! rov|ded by the Amer|can D|abetes
Assoc|anon and the Amer|can Co||ege of
Sports Med|c|ne
! At |east 1S0 m|nutes of moderate-|ntens|ty
aerob|c exerc|se per week as we|| as
res|stance exerc|ses on at |east three, and
preferab|y hve, days per week, prov|ded
that there are no contra|nd|canons (nanse| et a|.,
2010, Sanz et a|., 2010, Ump|erre et a|., 2011)
nSICAL AC1IVI1 ADVICL VLkSUS
S1kUC1UkLD LkLkCISL kCGkAMS
! hys|ca| acnv|ty (A) adv|ce a|one has not
been assoc|ated w|th |mprovements |n
g|ycem|c contro| for 12DM panents (W|sse et a|.,
2010, Ump|erre et a|., 2011)
! Structured exerc|se programs have y|e|ded
s|gn|hcant |mprovements |n g|ycem|c
contro| for 12DM panents
WnA1 IS 1nL C1IMAL LkLkCISL
1kAINING kCGkAM ICk INDIVIDUALS
WI1n 12DM?
! 1he opnma| tra|n|ng moda||ty or m|x of
moda||nes has not yet been |dennhed (n|||s et
a|., 2009, Sanz et a|., 2010)
! 1he |mpact of tra|n|ng sess|on duranon and
frequency of exerc|se on g|ycem|c contro| |s
current|y unknown (nansen et a|., 2010)
STATEMENT OF THE
RESEARCH PROBLEM
! 1he purpose of th|s rev|ew was to
determ|ne the most benehc|a| tra|n|ng
program for |nd|v|dua|s w|th 12DM by
eva|uanng the eects of A1, k1, and C1
exerc|se programs on g|ycem|c contro|, |n
terms of nbA1c va|ues
HYPOTHESIS
! C1 exerc|se programs w||| have the most
s|gn|hcant eect on |mprov|ng g|ycem|c
contro| |n |nd|v|dua|s w|th 12DM
CnAkAC1LkIS1ICS CI S1UDILS INCLUDLD
IN 1nL kLVILW CI LI1LkA1UkL
! 12DM panents on|y
! Sub[ects were at |east 19 years of age
! G|ycem|c contro| was measured by change
|n nbA1c va|ue
! Stud|es that were pub||shed between 2007
and 2011
SUMMARY OF RESULTS
AND CONCLUSIONS
Cut||ne:
! A1 8esulLs and Concluslons
! 81 8esulLs and Concluslons
! C1 8esulLs and Concluslons
! Cverall Concluslons
! Compllcaung lacLors
! Suggesuons for luLure research
A1 kLSUL1S: SIGNIIICAN1 CnANGLS IN
n8A1C VALULS (S S1UDILS)
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
Arora eL al. (2009) 8 weeks 3 (30 mlnuLes each) 8.11.9 Lo 6.66.
9, p < .03
Pansen eL al.
(2009)
6 monLhs 3 (Ll group: 33
mlnuLes aL 30
vC
2peak
, Pl group:
40 mlnuLes aL 73
vC
2peak
)
Ll group: 7.4.3 Lo
7.2.3, p < .01
Pl group: 7.1.2
Lo 6.6.18, p < .01
Marcus eL al. (2008) 16 weeks 3 (up Lo 30 mlnuLe
sesslons)
6.31.2 Lo
6.01.1, p = .02
Slgal eL al. (2007) 6 monLhs 3 (13-20 mlnuLes
up Lo 43-mlnuLe
sesslon)
7.411.3 Lo
6.981.3, p = .007
?avarl eL al. (2010) 16 weeks 3 (40 mlnuLes up Lo
90 mlnuLes)
8.331.29 Lo
7.61.04, p = .001
A1 kLSUL1S: INSIGNIIICAN1 CnANGLS IN
n8A1C VALULS (6 S1UDILS)
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
Church eL al. (2010) 9 monLhs 140 mlnuLes per
week
7.36.07 Lo 7.43.
08, ! = .14
Lrlksen eL al. (2007) 4 Lo 3 weeks 6 days per week (C
3x10: 3 10-mlnuLe
sesslons per day, C
1x30: 1 30-mlnuLe
sesslon per day)
C 3x10: 93 Cl: -.8
(-2.7 Lo 1.3), ! = .41
C 1x30: 93 Cl: -2
(-6.4 Lo 2.6), ! = .33
!orge eL al. (2011) 12 weeks 3 (20 mlnuLes each) 7.631.7 Lo
7.421.48, ! > .03
Lambers eL al.
(2007)
3 monLhs 3 (30 mlnuLes each) 7.41.7 Lo
71.61, ! > .03
ng eL al. (2010) 8 weeks 2 Lo 3 (30 mlnuLes
each)
8.3.9 Lo
8.11.1, ! > .03
vancea eL al. (2008) 16 weeks 3 or 3 per week (30
mlnuLes each)
C3: 8.21.9 Lo
7.41.2, ! > .03
C3: 7.71.8 Lo
7.4.8, ! > .03
AT CONCLUSIONS
A1 programs are most benehc|a| |n |mprov|ng
nbA1c va|ues for 12DM panents when:
! 1hey are a mlnlmum of 8 weeks (Slgal eL al., 2007,
Marcus eL al., 2008, Arora eL al., 2000, Pansen eL al., 2009, ?avarl eL al., 2010)
! lndlvlduals exerclse 3 umes per week (Slgal eL al.,
2007, Marcus eL al., 2008, Arora eL al., 2000, Pansen eL al., 2009, ?avarl eL al., 2010)
! lnLenslLy ls elLher low-moderaLe or hlgh*
(Pansen eL al., 2009)
k1 kLSUL1S: SIGNIIICAN1 CnANGLS
IN n8A1C VALULS (3 S1UDILS)
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
Arora eL al. (2009) 8 weeks 2 (3 seLs of 10
repeuuons each)
7.371.4 Lo 6.23.
8, ! < .03
Mlsra eL al. (2008) 12 weeks 3 (2 seLs of 10
repeuuons each)*
7.72.47 Lo 7.18.
33, ! < .001
Slgal eL al. (2007) 6 monLhs 3 (3 seLs of 7-9
repeuuons each)
7.48.47 Lo
7.181.32, ! = .
038
k1 kLSUL1S: INSIGNIIICAN1 CnANGLS
IN n8A1C VALULS (6 S1UDILS)
Study Duranon of
Intervennon
Sess|ons per Week
Change |n nbA1c
va|ue
Cheung eL al.
(2008)
4 monLhs (home-
based)
3 (88 Lralnlng: 2
seLs of 12
repeuuons each)
Changes of .3.9, !
= .30
Church eL al.
(2010)
9 monLhs 3 (2 Lo 3 seLs of
10-12 repeuuons
each)
7.38.07 Lo 7.33.
08, ! = .32
Pazley eL al.
(2010)
8 weeks 2 (2 seLs of 13
repeuuons each)
7.71.2 Lo
7.61.3, ! > .03
!orge eL al. (2011) 12 weeks 3 (20 mlnuLes
each)
8.312.43 Lo
8.24213, ! > .03
ng eL al. (2010) 8 weeks 2 Lo 3 (30 mlnuLes
each of clrculL
Lralnlng)
8.91.3 Lo
8.41.2, ! > .03
loLnlko eL al.
(2010)
16 weeks (home-
based)
3 (3 seLs of 8-10
repeuuons each)
6.91.3 Lo
6.971.33, ! = .27
k1 CCNCLUSICNS
k1 programs are most benehc|a| |n |mprov|ng
nbA1c va|ues for 12DM panents when:
! 1hey are a mlnlmum of 8 weeks (Slgal eL al., 2007, Mlsra
eL al., 2008, Arora eL al., 2009)
! lndlvlduals exerclse 2 Lo 3 umes per week (Slgal
eL al., 2007, Mlsra eL al., 2008, Arora eL al., 2009)
Also, home-based 81 programs are lneecuve
ln lmprovlng PbA1c values ln 12uM pauenLs
(Cheung eL al., 2008, loLnlko eL al., 2010)
CT RESULTS: SIGNIFICANT CHANGES
IN HBA1C VALUES (9 STUDIES)
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
8alduccl eL al. (2010) 1 year 130 mlnuLes per
week (plus exerclse
counsellng and a
300-calorle declL
dleL)
7.121.4 Lo
6.71.1, ! < .001
ChrlsLos eL al. (2009) 16 weeks 4 (2 A1 and 2 81
sesslons per week)
7.91.3 Lo 6.7.
9, ! < .001
Church eL al. (2010) 9 monLhs 110 mlnuLes of A1
per week and 30-40
mlnuLes of 81 per
week
7.39.07 Lo 7.36.
08, ! = .03
ue leyLer eL al.
(2007)
3 monLhs 3 (43-mlnuLes each) 7.6.3 Lo 7.2.2,
! = .04
Lambers eL al.
(2007)
3 monLhs 3 (30 mlnuLes each
of clrculL Lralnlng)
7.41.43 Lo
6.91.2, ! < .03
CT RESULTS CONTINUED: SIGNIFICANT
CHANGES IN HBA1C VALUES
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
Marcus eL al. (2008) 16 weeks 3 (up Lo 30 mlnuLes
of A1 and up Lo 20
mlnuLes of 81)
7.11.2 Lo
6.31.3, ! = .02
Ckada eL al. (2010) 3 monLhs 3 Lo 3 (40 mlnuLes
of A1 and 20
mlnuLes of 81 plus
dleLary and medlcal
lnLervenuons)
8.31.8 Lo 71.3,
! < .001
SergesLrm eL al.
(2010)
6 monLhs 2 (up Lo 23 mlnuLes
of A1 plus 81)
6.61.2 Lo 6.11,
! < .03 for hlgh-
volume group
sub[ecLs only*
Slgal eL al. (2007) 6 monLhs 3 (up Lo 43 mlnuLes
of A1 plus 81)
7.461.48 Lo
6.361.33, ! = .
001
C1 kLSUL1S: INSIGNIIICAN1 CnANGLS IN
n8A1C VALULS (2 S1UDILS)
Study Duranon of
Intervennon
Sess|ons per
Week
Change |n nbA1c
va|ue
Pordern eL al.
(2008)
4 weeks* 2 (60 mlnuLes each
plus educauon on
8 levels, llpld
levels, and smoklng
cessauon)
Changes of -.1.8,
! > .03
!orge eL al. (2011) 12 weeks 3 (20 mlnuLes each) 7.61.12 Lo
7.331.03, ! > .03
C1 CCNCLUSICNS
C1 programs are most benehc|a| |n |mprov|ng
nbA1c va|ues for 12DM panents when:
! 1hey are a mlnlmum of 3 monLhs (ue leyLer eL al.,
2007, Lambers eL al., 2007, Slgal eL al., 2007, Marcus eL al., 2008, ChrlsLos eL al.,
2009, 8alduccl eL al., 2010, Church eL al., 2010, Ckada eL al., 2010, SergesLrm eL al.,
2010)
! lndlvlduals exerclse aL leasL 2 umes per week
(ue leyLer eL al., 2007, Lambers eL al., 2007, Slgal eL al., 2007, Marcus eL al.,
2008, ChrlsLos eL al., 2009, 8alduccl eL al., 2010, Church eL al., 2010, Ckada eL
al., 2010, SergesLrm eL al., 2010)
CVLkALL CCNCLUSICNS
! A1, k1, and C1 promote s|gn|hcant
|mprovements |n g|ycem|c contro| for 12DM
panents
! C1 showed to |mprove nbA1c |n the
ma[or|ty of the stud|es rev|ewed, wh||e
resu|ts for stud|es on A1 and k1 were more
m|xed
nCWLVLk.
! Many factors were d|scovered to aect
changes |n nbA1c |eve|s, wh|ch therefore
comp||cated the conc|us|ons that were ab|e
to be deduced*
! 8asellne PbA1c value
! SLudy durauon
! uurauon of exerclse sesslons
! 8ace and eLhnlclLy
! uleL and medlcauon
8ASLLINL n8A1C VALUL
! Good (< 7.1S) versus poor (> 7.1S)
g|ycem|c contro| at base||ne (Pordern eL al., 2008)
! Iurther s|gn|hcant reducnons w|th h|gher
va|ues at base||ne (8alduccl eL al., 2010)
! Aects what type of tra|n|ng e||c|ts
s|gn|hcant reducnons |n va|ues (Slgal eL al., 2007)
S1UD DUkA1ICN
! 4 weeks or |ess ! Ins|gn|hcant changes |n
nbA1c va|ues regard|ess of the tra|n|ng
moda||ty (Lrlksen eL al., 2007, Pordern eL al., 2008)
! 8 weeks ! M|xed resu|ts, regard|ess of the
tra|n|ng moda||ty (Arora eL al., 2009, Pazley eL al., 2010, ng eL al., 2010)
! 2 to 3 months and |onger ! Not necessar||y
s|gn|hcant changes |n nbA1c va|ues. Stud|es
that ranges from 12 weeks to 1 year y|e|ded
|ns|gn|hcant resu|ts (!orge eL al., 2011, loLnlko eL al., 2010, Cheung
eL al., 2008, vancea eL al., 2008)
DUkA1ICN CI LkLkCISL SLSSICNS
! Stud|es that eva|uated more than one
exerc|se |ntervennon ! sub[ects cou|d have
exerc|sed for d|erent duranons (Slgal eL al., 2007,
Marcus eL al., 2008)
! Makes |t |mposs|b|e to make dehn|nve
conc|us|ons
kACL AND L1nNICI1
! Certa|n ethn|c groups tend to be more
|nsu||n res|stant than others (Mlsra eL al., 2008, Wlnnlck eL
al., 2008, Arora eL al., 2009, ng eL al, 2010)
! ln a sLudy LhaL sLraued sub[ecLs by race,
Afrlcan Amerlcan sub[ecLs LhaL performed a 81 program
experlenced greaLer lmprovemenLs ln lnsulln sensluvlLy
and body welghL Lhan whlLe Caucaslan sub[ecLs LhaL
compleLed Lhe same 81 lnLervenuon* (Wlnnlck eL al., 2008).
DIET AND MEDICATION
! D|et and Med|canon are cornerstones of
d|abetes management, |n add|non to
exerc|se (Pansen eL al., 2010, Sanz eL al., 2010, umplerre eL al., 2011
" 2 sLudles conLrolled for dleL only (Slgal eL al., 2007, ChrlsLos eL
al., 2009 )
" 3 sLudles conLrolled for medlcauon only (ue leyLer eL al.,
2007, Cheung eL al., 2008, Pansen eL al., 2009, Church eL al., 2010, ?avarl eL al.,
2010)
" 2 sLudles conLrolled for boLh (8alduccl eL al., 2010, Ckada eL al.,
2010)
! Makes |t |mposs|b|e to make dehn|nve
conc|us|ons about the eect of the exerc|se
|ntervennon
FUTURE RESEARCH
! Shou|d focus on conducnng stud|es that
address the comp||canng factors
! Iuture research shou|d:
! SLraufy sub[ecLs by basellne PbA1c value
! 8e aL leasL 12 weeks ln durauon
! Pave sub[ecLs ln all lnLervenuon groups exerclse for
Lhe same durauon
! SLraufy sub[ecLs by race and eLhnlclLy
! ConsulL a 8eglsLered uleuuan Lo place all sub[ecLs on
Lhe same dleL, advlse Lhem on how Lo follow Lhe dleL,
and measure sub[ecL compllance
! MonlLor medlcauons and any changes ln dosages

A1 kLSLN1.
! Lv|dence from the ||terature shows that A1,
k1, and C1 each |mprove g|ycem|c contro| |n
12DM sub[ects, w|th C1 potenna||y e||c|nng
the greatest benehts.
! nowever, the most opnma| tra|n|ng
moda||ty for the 12DM popu|anon cannot
be dehn|nve|y determ|ned unn| future
research addresses and contro|s for the
many comp||canng factors that eect
g|ycem|c contro|.