501 - 2.physical Activity and Prevention and Treatment of Diabetes - DR Ashley Cooper

Physical activity and
prevention and treatment of

diabetes
Ashley Cooper
University of Bristol
ashley.cooper@bris.ac.uk
Type 2 diabetes
One of the most common
Relative risk of Type II diabetes
disorders, affecting
people of all ages
In England ~2.2million
people have type 2
diabetes
T2DM and obesity are
intimately linked: 80-
90% of people with T2DM
are also obese
Severe long term
consequences
Body Mass Index
Expensive to manage
Evidence for the health benefits
of physical activity
The general “healthy” population

Those at high risk of diabetes
People who have diabetes
The role of sedentary behaviour
Physical activity and risk of
type 2 diabetes
Review of studies published 1991-2006
20 studies representing 13 cohorts
353 - 87,253 participants, 4-16 yrs follow up
7 female only, 7 men only
24-74 yrs old at recruitment
USA, Europe and Asia
Wide range of exercise modalities from episodes of
vigorous activity to active commuting
Gill & Cooper (2008). Sports Medicine 38: 807-824

Physical activity and risk of
type 2 diabetes
Vigorous exercise 5x/week Walking associated with an

associated with 42% reduction approximately 50% reduction in
in risk in men risk in women
Manson et al 1992. JAMA;268:63-67 Hu et al (1999) JAMA, 282:1433-1439
A Men age-adjusted B Men multivariate-adjusted
(including BMI-adjusted)
C Women age-adjusted D Women multivariate-adjusted

(including BMI-adjusted)
Gill & Cooper (2008). Sports Medicine 38: 807-824

Summary: prevention of
diabetes
Physical activity is protective against type 2 diabetes
in the general population with a reduction in risk of
10-40%
This is observed in men and women, across the BMI
range and across ethnic groups
Current physical activity guidelines are appropriate for
prevention of type 2 diabetes
Recommendation Evidence
Over a week, activity should add up to at least 150 Strong
minutes (2½ hours) of moderate intensity activity.
Comparable benefits can be achieved through 75 Strong
minutes of vigorous intensity activity spread
across the week or a combination of moderate and
vigorous intensity activity.
Start Active, Stay Active (2011)
What is the role of physical
activity in the prevention of type
2 diabetes in those at high risk?
At least 2.5 h/week of moderate to vigorous PA A
should be undertaken as part of
lifestyle changes to prevent type 2 diabetes onset
in high-risk adults.
ADA/ACSM guidelines (2010) Diabetes Care 33: e147-167

Prevention of diabetes in those
at high risk
There have been several major prevention trials
Malmo Feasibility Study
Da Qing Study
Finnish Diabetes Prevention Study
US Diabetes Prevention Program
Indian Diabetes Prevention Programme
Reduction in incidence of diabetes as the
outcome
Focus on lifestyle rather than physical activity
Lifestyle intervention targets
Intervention groups received a multi-component
lifestyle intervention
Individualised counselling/encouragement aimed
at:
Increasing physical activity by ≥ 30 min per day
Reducing body mass by ≥ 5%
Reducing total fat to ≤ 30%
Reducing saturated fat to ≤ 10%
Increasing fibre intake to ≥ 15g per 1000 Kcal
Control groups received general oral and written

advice about diet and activity
The Finnish Diabetes Prevention
Study
58%
Tuomilehto et al (2001) NEJM, 344:1343-1350

US Diabetes Prevention
Program
58%
Knowler et al (2002) NEJM, 346:393-403

Indian Diabetes Prevention
Programme
28%
Control
Metformin
Lifestyle
Lifestyle + Metformin
Ramachandran et al (2006) Diabetologia, 49:289-297

Diabetes prevention:
physical activity or weight loss?
Reductions in diabetes incidence occurred in trials
inducing no weight loss:
46% reduction in Exercise only arm of Da Qing study
28.5% reduction in Indian DPP
But greater reductions in diabetes incidence were

observed in trials where weight loss occurred:
63% reduction in Malmo Feasibility Study
58% reduction in Finnish DPP
58% reduction in USDPP
What is the independent effect of physical activity?

What is the magnitude of effect
of physical activity?
Studies limited by poor physical activity measurement
In the Finnish DPS post hoc analyses identified a 49% difference

in risk of T2DM between highest & lowest tertiles of MVPA
Difference in MVPA between highest and lowest tertiles was 246

minutes per week
The difference of 120 minutes of MVPA between lowest and

middle tertile was not associated with reduced risk of diabetes
These data suggest that the guidelines of 150 minutes/week are

insufficient to prevent diabetes in the absence of other lifestyle
change
Yates et al (2007). Diabetologia 50:1116-1126

Summary: pre-diabetes
Lifestyle intervention involving diet and exercise can
prevent or delay progression to type 2 diabetes in
patients with impaired glucose tolerance
The independent effect of exercise is yet to be

determined but it is likely that in the absence of
dietary change, levels of physical activity in excess of
the current guidelines are required
What is the role of physical
activity in the management of
type 2 diabetes?
Persons with type 2 diabetes should undertake at B
least 150 min/week of moderate to
vigorous aerobic exercise spread out during at
least 3 days during the week
In addition to aerobic training, persons with type 2 B

diabetes should undertake
moderate to vigorous resistance training at least
2–3 days/week
Supervised and combined aerobic and resistance B/C
training may confer additional health
benefits
ADA/ACSM guidelines (2010) Diabetes Care 33: e147-167
The Early ACTID Study
593 patients with newly
diagnosed T2DM
3 groups: Gloucester
Usual care
Diet
Diet + exercise
1 year intervention
Home based exercise
intervention
Primary outcomes:
HbA1c and blood
pressure
Andrews et al (2011) Lancet 378: 129-139
Participant visits in Early ACTID
Screening x1
BL Measurements x2
Clinical review + Dietician x1

RANDOMISATION
Usual care (n=110) Diet only (n=320) Diet + exercise (n=320)
Dietician + Nurse x2 Dietician + Nurse x2

Nurse only x4 Nurse only x4
6-month measurements x2 6-month measurements x2 6-month measurements x2

Clinical review x1 Clinical review + dietician x1 Clinical review + dietician x1
Dietician + nurse x1 Dietician + nurse x1

Nurse only x2 Nurse only x2
12-month measurements x2 12-month measurements x2 12-month measurements x2

Clinical review + Dietician x1 Clinical review + Dietician x1 Clinical review + Dietician x1
10 visits 19 visits 19 visits

Change in physical activity &
weight in Early ACTID
Compliance: 579 (98%) of participants still in study at 12 months

and 71% of visits attended
Andrews et al (2011) Lancet 378: 129-139
HbA1c
Usual
Diet
Diet + Ex
6 months Difference P value 12 months Difference P value

D vs D +E -0.05 0.56 D vs D +E -0.08 0.6
D vs U -0.28 0.002 D vs U -0.26 0.005
D +E vs U -0.33 <0.0001 D +E vs U -0.33 <0.0001
What type of exercise is effective
in people with diabetes?
Recent meta-analysis
identified 23 trials of
structured exercise and
24 trials of exercise
advice
Mixture of aerobic,
resistance and
combined programmes
Change in HbA1c was
outcome
>150 minutes -0.89%
<150 minutes -0.36%
Umpierre et al (2011) JAMA 305: 1790-1799

Summary: people with diabetes
Supervised aerobic & resistance exercise, and
both combined, had a similar magnitude of
effect (overall -0.67%)
Longer duration was more effective (above
current guidelines?)
No evidence of an intensity effect
Advice should be combined with diet
How much change is possible?
ACTID: 10 minutes
FDPS: 9 minutes
USDPP: 15 minutes
Umpierre et al (2011) JAMA 305: 1790-1799

Sedentary behaviour and health
Set of behaviours -
largely sitting
Watching TV, reading,
computer use, driving
Associations with
metabolic risk factors
2hr glucose, HOMA-IR,
HDL, waist
circumference
Prolonged TV viewing is
associated with greater
risk of type 2 diabetes
Grontved (2011) JAMA 305: 2448- 2455

Summary
Physical activity meeting current guidelines is
effective in preventing type 2 diabetes
In people with pre-diabetes, the independent
role of physical activity is unclear
In people with diabetes, structured exercise
appears to effective in improving glycaemic
control….
…but exercise advice alone may not be
sufficient
Future work will explore the potential for
targeting sedentary time

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Physical activity and

prevention and treatment of

The general “healthy” population

Gill & Cooper (2008). Sports Medicine 38: 807-824

Vigorous exercise 5x/week Walking associated with an

C Women age-adjusted D Women multivariate-adjusted

Gill & Cooper (2008). Sports Medicine 38: 807-824

ADA/ACSM guidelines (2010) Diabetes Care 33: e147-167

Control groups received general oral and written

Tuomilehto et al (2001) NEJM, 344:1343-1350

Knowler et al (2002) NEJM, 346:393-403

Ramachandran et al (2006) Diabetologia, 49:289-297

But greater reductions in diabetes incidence were

What is the independent effect of physical activity?

In the Finnish DPS post hoc analyses identified a 49% difference

Difference in MVPA between highest and lowest tertiles was 246

The difference of 120 minutes of MVPA between lowest and

These data suggest that the guidelines of 150 minutes/week are

Yates et al (2007). Diabetologia 50:1116-1126

The independent effect of exercise is yet to be

In addition to aerobic training, persons with type 2 B

Clinical review + Dietician x1

Usual care (n=110) Diet only (n=320) Diet + exercise (n=320)

Dietician + Nurse x2 Dietician + Nurse x2

6-month measurements x2 6-month measurements x2 6-month measurements x2

Dietician + nurse x1 Dietician + nurse x1

12-month measurements x2 12-month measurements x2 12-month measurements x2

10 visits 19 visits 19 visits

Compliance: 579 (98%) of participants still in study at 12 months

6 months Difference P value 12 months Difference P value

Umpierre et al (2011) JAMA 305: 1790-1799

Umpierre et al (2011) JAMA 305: 1790-1799

Grontved (2011) JAMA 305: 2448- 2455

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