ASPETTI METABOLICI DELL'ATTIVITA'FISICA - FRANCESCO MOLLO SOC DIABETOLOGIA E MALATTIE - Azisanrovigo.it
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
ASPETTI METABOLICI
DELL’ATTIVITA’FISICA
FRANCESCO MOLLO
SOC DIABETOLOGIA E MALATTIE
METABOLICHE
ULSS 18 – ROVIGO
INCONTRO DI AGGIORNAMENTO 7/11-5/12/2007I dati del diabete negli USA
Ogni 24 ore:
• 4.100 nuovi casi di diabete
• muoiono almeno 810 persone
• 230 vengono amputate
• 120 necessitano di dialisi o trapianto
• 55 diventano cieche
Vinicor F: Doc News, January 2006Stima dei costi sanitari per il diabete
negli USA (2002-2020)
200
Costi (miliardi $)
192
150
156
132
100
50
0
2002 2010 2020
ADA: Diabetes Care 26, 917-32, 2003Prevalenza delle anomalie
metaboliche nei diabetici
%
70
60 69
50
54
40 47
30 39
20
10
0
Obesità Add. IperTG Basse HDL IpertensionePrevalenza dell’obesità viscerale
nei diabetici tipo 2
Circonferenza addominale > 102 cm M, 88 cm F
80 Maschi
Femmine
79 75
60
%
40
41
35
20
0
SFIDA^ Metascreen*
^Comaschi MA, et al:GIDM 24, 155, 2004; *in pressINSULIN RESISTANCE: THE ORIGIN OF
SEVERAL ABNORMALITIES IN TYPE 2 DIABETES
AND THE METABOLIC SYNDROME
Hypertension Thrombophilia
Hyperglycemia
Dyslipidemia Hyperuricemia
INSULIN RESISTANCE
INSULIN
INSULIN RESISTANCE
RESISTANCE“Thrifty genotype”
“Being exceptionally
efficient in the intake and/or
the utilization of food”
Neel JV
Am J Hum Genet
14: 352-353, 1962
Chakravarthy M and Booth F.
Eating, exercise and “thrifty” genotypes….
J Appl Physiol 96: 3-10, 2004“L’UOMO E’ NATO PER CORRERE (BORN TO RUN)”
“La Corsa nell’evoluzione umana”
Dennis Bramble (Utah) & Daniel Lieberman (Harward)Condizione costante
di
“disadattamento all’ambiente”
Un organismo che cambia
in milioni di anni
in un ambiente che cambia
in decine di anniPrevenzione del T2D
Diabetes Prevention Program
Incidenza cumulativa di diabete di tipo 2
40
Placebo
Incidenza cumulativa di diabete (%)
Metformina RR
Stile di vita 31%
30
RR*
58%
20 NNT=14
NNT=7
10
0
0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Anni
* Riduzione del rischio di progressione del diabete di tipo 2 vs
placebo con dimagramento medio di 5kg (7%) + 2h1\2 DPP.N Engl J Med. 2002; 346: 393-403
settimanalmente di esercizio fisico moderatoAerobic vs. Resistance Training?? • Quale è più corretta? • Quale dà i maggiori benefici? • L’aerobica che brucia un maggior numero di calorie?? • Il Training di resistenza che fa lavorare una maggiore massa muscolare?? • Bisogna ricordare che noi cerchiamo di evitare le complicanze micro/macroangiopatiche e di migliorare l’attività insulinica…
Eriksson,J.
Aerobic Endurance Exercise or Circuit-Type Resistance Training
for Individuals with Impaired Glucose Tolerance.
Hormone. Metab. Res. 30(1998) 37-41.
Two groups – Aerobic/Endurance Training vs. Circuit/Resistance Training
10 weeks. 1 hour. 3x week. Moderate Intensity
Results: Increased VO2max, slight decrease bp, no change in insulin
sensitivity in aerobic group.
Increased HDL, increased insulin sensitivity in circuit group.
Conclusion: Impaired glucose tolerance, as reflected by insulin
resistance, is the underlying condition in diabetics an exercise program
that effectively increases insulin sensitivity is desired.
Circuit-type resistance training was shown to increase Insulin
sensitivity and thus glucose control.Brandenburg S.
Effects of Exercise Training on Oxygen Uptake Kinetic Responses in Women with
Type 2 Diabetes. Diabetes Care, 22(1999) 1640-1645.
Three Groups – 8 Overweight, Type II Diabetics
9 Overweight, Non-Diabetics
10 Lean, Healthy
*All participants were same age
Type II Diabetics had the lowest VO2max upon entry
3 months, 3 x week, 1 hour Aerobic Training, Moderate Intensity
Results: No change in body weight in any group.
Diabetics showed greatest increase in VO2max – 28% vs. 8% increase in
Non-diabetics, 5% in Lean
Diabetics showed 39% increase in VO2 kinetics
Conclusion: Aerobic training is effective means for increasing exercise
capacity and performance in diabetics.• Cardio Fitness
– VO2 Max
– VO2 Kinetics
– Slight decrease bp • Resistance Training
– Increase insulin
sensitivity
– Improve endothelial
function
– Improve lipid profile
– Increase bone densityThe “why” and “how” of RT
• La manifestazione primaria del Diabete tipo
2 si evidenzia a livello del metabolismo
muscolare per:
- Riduzione del trasporto di glucosio
- Riduzione dell’espressione di Glut4
- Riduzione dell’attività della glicogeno-
sintetasiNatural History of Type 2 Diabetes
Years from -10 -5 0 5 10 15
diagnosis
Onset Diagnosis
Insulin resistance
Insulin secretion
Postprandial glucose
Fasting glucose Microvascular complications
Macrovascular complications
Pre-diabetes Type 2 diabetes
Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789;
Nathan DM. N Engl J Med. 2002;347:1342-1349Ren, Jian-Ming. Exercise Induces Rapid Increases in GLUT4
Expression, Glucose Transport Capacity and Insulin-Stimulated
Glycogen Storage in Muscle. Journal of Biological Chemistry.
1994(269) 14396-407.
Three groups rats – 1 Day Swimmers & 2 Day Swimmers & Control
Two 3 hour bouts swimming per day.
Dissected forelimb muscle out and analyzed.
Results: 1 day swimmers had 2 fold increase in GLUT4 mRNA
2 day swimmers had slight increase from 1 day swimmers
1 day swimmers had 55% increase in GLUT4 protein expression
2 day swimmers had 95% increase in GLUT4 protein expression
Conclusion: The rapid adaptation to exercise is to prevent
hypoglycemia and fatigue during prolonged exercise. Exercise proves
to be an effective stimulus of GLUT4 up-regulation.Henriksson, H.
Exercise in the Management of Non-Insulin Dependent Diabetes Mellitus.
Sports Medicine. 1998,Jan 25 (1).
Ha rilevato che in soggetti non diabetici, l’esercizio ha scarso effetto sui
livelli di glucosio nel sangue, ma, in pazienti diabetici di tipo II, modelli di
esercizio sono associati ad una diminuzione dei livelli di glucosio nel sangue.
Perché? Hanno una ridotta risposta ormonale
Durante l'esercizio dovrebbe diminuire la secrezione di insulina
ed aumentare quella di glucagone. Allora, come fa il glucosio
ad entrare nel muscolo scheletrico?
Le contrazioni muscolari stimolano i recettori del GLUT4
indipendentemente dall’ insulina e ciò è evidente nei
diabetici con resistenza all'insulina.Characteristics of Type II Diabetes
• Characteristics
– Insulin Resistance
• Defective intracellular insulin signaling
• Hyperinsulinemia & Hyperglycemia
– Central Obesity
• Chronic Low-Grade Inflammation
• Pre-mature Arterial Stiffening
– Endothelial Dysfunction
– Poor Lipid Profile
• Atherosclerosis
– Low Bone Density
• Diabetic at risk for fractures & Charcot Foot
– Peripheral Neuropathy
• Increased fall risk
• AmputationsExercise (Catecholamine Stimulation) is Necessary for
Mobilization of Visceral Abdominal Fat.
Giannaooulou, I. Exercise is Required for Visceral Fat Loss in Postmenopausal Women
with Type 2 Diabetes. Journal of Clinical Endocrinology and Metabolism. 2005, 90 (3).
Three groups – Diet alone, Exercise alone, Diet + Exercise
3x week/50 min Aerobic Training, Moderate Intensity
Results: MRI analysis showed decrease in total abd fat and SAT in all
three groups.
Significant decrease in VAT in E, D+E groups but not in D
group.
Conclusion: D and D+E were effective at decreasing total abd fat and
SAT however exercise is required for reduction of VAT in
type 2 diabetics.
WHY? Visceral adipocytes are more responsive to
catecholamine stimulation associated with exercise.CONTRIBUTION OF GLUCOSE AND FFA
IN RELATION TO EXERCISE INTENSITY
GLUCOSE FFA
60
Glucose and FFA Ra
(µmol·kg-1·min-1)
50
40
30
20
10
0
% VO2 max 10 20 30 40 50 60 70 80 90 100
Brooks and Trimmer J Appl Physiol 80: 1073, 1996Exercise and Chronic
Low-Grade Inflammation
• La letteratura scientifica documenta una
relazione inversa tra grado di
infiammazione cronica ed esercizio fisico
per:
1. Down-regulation di geni pro-infiammatori
2. Up-regulation di geni anti-infiammatoriCharacteristics of Type II Diabetes
• Characteristics
– Insulin Resistance
• Defective intracellular insulin signaling
• Hyperinsulinemia & Hyperglycemia
– Central Obesity
• Chronic Low-Grade Inflammation
• Pre-mature Arterial Stiffening
– Endothelial Dysfunction NO-and insulin dep.
– Poor Lipid Profile
• Atherosclerosis
– Low Bone Density
• Diabetic at risk for fractures & Charcot Foot
– Peripheral Neuropathy
• Increased fall risk
• AmputationsHigh Intensity RT is an Effective Means to Increasing NO-Dependent
. Vasodilation in Type II Diabetics
Two groups – Exercise and Control Group
8 weeks, 1 hour, 3x week, Circuit-Resistance Training, High Intensity
Results: Flow-mediated dilation of brachial artery was significantly
increased after exercise. This is an NO-dependent vessel.
What was interesting was that all exercises were limited to the
LE but the improved UE vasodilation suggests the NO-dilation
effect is generalized.
Maiorana, Andrew. The Effect of Combined Aerobic and Resistance Exercise Training on
Vascular Function in Type 2 Diabetes.
Journal of American College of Cardiology. 2001 Sep; 38 (3): 860-6Vasodilation
• Benefits of exercise
– Increased flow increased shearing stress to
endothelium
– Increased NO-synthase activity
– Stimulated release of NOCharacteristics of Type II Diabetes
• Characteristics
– Insulin Resistance
• Defective intracellular insulin signaling
• Hyperinsulinemia & Hyperglycemia
– Central Obesity
• Chronic Low-Grade Inflammation
• Pre-mature Arterial Stiffening
– Endothelial Dysfunction
– Poor Lipid Profile
• Atherosclerosis
– Low Bone Density
• Diabetic at risk for fractures & Charcot Foot
– Peripheral Neuropathy
• Increased fall risk
• AmputationsLipid Profile • At risk for atherosclerosis/CAD – HDL < 35 mg/dl – LDL > 160 mg/dl – TG > 250 mg/dl • Associated risk due to visceral abdominal fat and direct portal link
High Intensity RT is Effective in Lowering TC, LDLs and TGs
in Type II Diabetics
Two groups – Circuit training vs. Control
5 months, 1 hour, 2x week, High Intensity
Results: Decrease total cholesterol 12%
Decrease LDL by 14%
Decrease TG by 20%
Conclusion: RT is an effective means to improving overall metabolic profile
in type II diabetics.
*Important outcome is that hypertensive patients previously discouraged
from RT due to risk of MI, were shown to have positive outcomes and
actually reduced their risk with an associated decrease bp and L. ventricle
size.
Honkola, A. Resistance Training Improves the Metabolic Profile in Individuals with
Type 2 Diabetes. Acta Diabetol (1997) 34: 245-248.Characteristics of Type II Diabetes
• Characteristics
– Insulin Resistance
• Defective intracellular insulin signaling
• Hyperinsulinemia & Hyperglycemia
– Central Obesity
• Chronic Low-Grade Inflammation
• Pre-mature Arterial Stiffening
– Endothelial Dysfunction
– Poor Lipid Profile
• Atherosclerosis
– Low Bone Density
• Diabetic at risk for fractures & Charcot Foot
– Peripheral Neuropathy
• Increased fall risk
• AmputationsPeripheral Neuropathy • 3 types – Autonomic – Mononeuropathy – Polyneuropathy* • DPN affects 70% of diabetics • Leading cause of non-traumatic foot & leg amputations • Associated loss of vibratory sensation, muscle tone and balance • Primary tx is glycemic control
Exercise is Effective at Preventing Peripheral
Neuropathy in Type II Diabetics
Two groups – Exe + Control
4 year study, Brisk walking program
Results: Peroneal n. NCV increased in Exe group and decreased in control group.
Significant improvement of hallux VPT in Exe and diminished in control.
17% of Control developed PN – 0.0% of Exe group developed PN
Conclusion: Long-term aerobic training (i.e. walking) can prevent the natural onset
of PN in type II diabetics. Was probably associated to exercise-induced
vasodilation.
*Note that researchers chose brisk walking as it is easily reproducible to general diabetic
population.
Balducci, S. Exercise Training can Modify the Natural History of Diabetic
Peripheral Neuropathy. Journal of Diabetes and its Complications. 2006 20(4),
216-223.p 40
Peso Kg + 0.8 + 0.6 + 0.1 - 2.2 - 3.0 - 3.2
Cm vita + 1.0 + 1.0 - 0.9 - 3.8 - 5.5 - 7.1
HBA1c % + 0.03 - 0.06 - 0.44 - 0.88 - 1.11 - 1.19
PA max mmHg - 1.8 - 1.5 - 6.4 - 5.5 - 6.6 - 9.2
PA min mmHg - 4.6 - 2.4 - 2.9 - 4.8 - 5.3 - 7.1
COL tot mg% - 3.8 - 5.6 - 10.2 - 10.7 - 7.4 - 10.9
COL LDL mg% - 4.5 - 7.1 - 3.4 - 5.3 - 6.3 - 7.7
COL HDL mg% + 0.1 + 1.1 + 2.9 + 5.6 + 10.4 + 6.3
TG mg% + 3.4 + 2.1 - 48.2 - 55.2 - 57.4 - 68.4
CHD % + 0.1 - 0.3 - 2.6 - 3.7 - 4.8 - 4.3
Di Loreto et al. Diabetes Care 2005Modifiche della spesa SSN dopo 2 anni
p40
GRUPPI (MET)
Di Loreto et al. Diabetes Care 2005…prima di preoccuparci di chiedere al medico se l’attività fisica può farci bene ...dovremmo prioritariamente preoccuparci di chiedergli se il nostro organismo potrà sopportare la sedentarietà verso la quale non ha nessun tipo di difesa programmata
You can also read
