Improving Health through lifestyle modification

Not to be copied without written permission from Kenneth L Miller, PT, DPT © 2018 1

Improving Health through Lifestyle Modification:

Physical Activity Prescription and Chronic Disease Management

Kenneth L Miller, PT, DPT, GCS, CEEAA

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Learning Objectives

By the end of this program participant will be able to:

• List 3 non-communicable diseases that are preventable with appropriate lifestyle behaviors.

• Explain the difference between restorative care and preventive care.

• Distinguish between primary and secondary prevention in a physical therapy plan of care.

• Apply use of the physical activity vital sign as an assessment tool within the physical therapy examination.

• Design a wellness/prevention treatment plan incorporating dosing and intensity parameters into the interventions prescribed.

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Introduction/Background

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Background Facts – Global Data

• The World Health Organization (WHO) has stated that Non-Communicable Diseases (NCD) are the leading causes of death and disability in the world.

• Non-communicable diseases are non-infective, and non-transmissible conditions that occur as a result of behavioral and/or genetic factors having a slow progression and long duration.1

• These diseases are considered to be highly preventable with lifestyle behaviors including diet and sufficient physical activity.2,3,4

• Examples of NCDs include: cardiovascular disease (CVD), cancer, chronic respiratory disease and diabetes.

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Non-communicable diseases (NCDs)

• 70% of deaths globally,

• 37% in low-income countries to 88% in high-income countries.

• All but 1 of the 10 leading causes of death in high-income countries were NCDs.

• In terms of absolute number of deaths, however, 78% of global NCD deaths occurred in low- and middle-income countries.

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World Health Organization (WHO)

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WHO

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WHO

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Background Facts – US Data

• Chronic Diseases are: • most costly• most common• preventable• accounts for 7 of the top 10 reasons for death.

• Almost half of U.S. Adults have at least 1 chronic disease.• About half of US adults (47%) have at least one of the following major risk

factors for heart disease or stroke: • uncontrolled high blood pressure, • uncontrolled high LDL cholesterol, or are current smokers.• Ninety percent of Americans consume too much sodium, increasing their risk of high

blood pressure.

• Eighty-six percent of all health care spending in 2010 was for people with one or more chronic medical conditions.

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Background Facts

• The total cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in decreased productivity.

• Decreased productivity includes costs associated with people being absent from work, being less productive while at work, or not being able to work at all because of diabetes.

• Of adults aged 18 years or older:• 52% did not meet recommendations for aerobic exercise or physical activity.

• 76% did not meet recommendations for muscle-strengthening physical activity.

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Background Facts

• Obesity is a serious health concern. During 2009–2010, more than one-third of adults, or about 78 million people, were obese (defined as body mass index [BMI] ≥30 kg/m2). Nearly one of five youths aged 2–19 years was obese (BMI ≥95th percentile).

• Mobility disability and dementia, are strongly and independently associated with short- and long-term mortality among older persons hospitalized with HF.

• Frailty is a common and important geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multi-organ systems, leading to increased vulnerability for adverse health outcomes.

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CMS Readmissions Reduction Program (HRRP) • Requires CMS to reduce payments to IPPS hospitals with excess readmissions

• Readmissions within 30 days of dc from acute hospital• FY 2012 Adopted readmission measures for the applicable conditions:

• acute myocardial infarction (AMI)• heart failure (HF)• pneumonia (PN)

• FY2015 expansion of the applicable conditions• acute exacerbation of chronic obstructive pulmonary disease (COPD)• elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)

• FY 2016 additional pneumonia diagnoses• aspiration pneumonia• sepsis patients coded with pneumonia present on admission (but not including severe sepsis)

• FY2017 program to include• coronary artery bypass graft (CABG)

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Hospital Re-Admission Risk Factors

• Medical complexity

• Age

• Comorbidities

• Access to care

• Hospital length of stay

• Social support

• Impaired physical function

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Age-adjusted Percentage of Adult Population With Selected Chronic Disease Risk Factors and Conditions, by Year, United States, 1999–2012†

Risk factor or condition 1999 – 2000 2005 – 2006 2009 – 2010̓a

Diabetesb 9.0 10.4 11.5

High cholesterolb 25.0 27.0 26.7

Hypertensionb 30.0 30.5 30.0

Obesityb 30.5 34.4 35.7

Current cigarette smokingc

23.1 20.8 19.3

Did not meet physical activity guidelinesd

54.7 N/A 49.1

Binge drinkinge 14.9f 15.4g 15.8h

† Source: Health, United States, 2012 (http://www.cdc.gov/nchs/data/hus/hus12.pdf) unless otherwise indicated; data include estimates of meeting physical activity guidelines for 2011 and current cigarette smokers for 2012. a For prevalence of “current cigarette smokers”, estimate for 2012 is as indicated in footnote “c” below; for prevalence of “did not meet physical activity guidelines”, estimate for 2011 is as indicated in footnote d below. b Percentage of persons ≥20 y (source: NHANES). c Percentage of persons ≥18 y who were current cigarette smokers (years: 2000, 2005, 2010); for 2012, the prevalence was 18.0% (source: National Health Interview Survey). d Percentage of persons ≥18 y who met neither aerobic activity or nor muscle-strengthening 2008 federal physical activity guidelines (years 2000 and 2010); for 2011, the prevalence was 47.6% (source: National Health Interview Survey). e Source: BRFSS. Estimates are not age-adjusted. f Percentage of persons 18 y and over who consumed ≥5 drinks on ≥1 occasion(s) during the past month (1999 only). g Percentage of males ≥18 y who consumed ≥5 drinks and females ≥18 y who consumed ≥4 drinks on ≥1 occasion(s) during the past 30 days (2006 only). h Percentage of males ≥18 y who consumed ≥5 drinks and females ≥18 y who consumed ≥4 drinks on ≥1 occasion(s) during the past 30 days (2009 only).

http://www.cdc.gov/nchs/data/hus/hus12.pdf


Chronic Diseases and Health Conditions

Most common, costly, and preventable of all health problems

• heart disease

• stroke

• cancer

• type 2 diabetes

• Obesity - more than one-third of adults, or about 78 million people, were obese (defined as body mass index [BMI] ≥30 kg/m2 (2009-2010)

• Arthritis - most common cause of disability

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Rankb Cause of Death ICD-9 Codec NumberDeath Rate

Age-Adjusted Death Rate

1 Diseases of the heart I00-I09, I11, I13, I20-I51 596,339 191.4 173.7

2 Malignant neoplasms C00-C97 575,313 184.6 166.6

3Chronic lower respiratory diseases

J40-J47 143,382 46.0 42.7

4 Cerebrovascular diseases I60-I69 128,931 41.4 37.9

5Accidents (unintentional injuries)

V01-X59, Y85-Y86 122,777 39.4 38.0

6 Alzheimer’s disease G30 84,691 27.2 24.6

7 Diabetes mellitus E10-E14 73,282 23.5 21.5

8 Influenza and pneumonia J09-J18 53,667 17.2 15.7

9Nephritis, nephroticsyndrome, and nephrosis

N00-N07, N17-N19, N25-N27

45,731 14.7 13.4

10Intentional self-harm (suicide)

U03, X50-X84, Y87.0 38,285 12.3 12.0

Top 10 Causes of Death, United States, 2011

Adapted from Hoyert DL, Xu J. Deaths: Preliminary data for 2011. Natl Vital Stat Rep. 2012;61(6):1-51. Rates are per 100,000 population; age-adjusted rates per 100,000 US standard population based on the year 2000 standard. a Based on number of deathsb New subcategories replaced previous ones for N18 (Chronic kidney disease) in 2011. Changes affect comparability with previous year’s data. 17

http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf


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Do you know…

• The role of physical therapists in of cardiovascular disease, stroke and diabetes?

• Physical therapists are well educated and positioned to work in wellness and preventative care (primary and secondary prevention) of CVD, stroke and diabetes to improve population health.5

• Physical activity and exercise prescription are key to physical therapist practice and use of the physical activity vital sign (PAVS) and/or wearable trackers will be incorporated to ensure that dosing and intensity are sufficient to achieve the health benefits to prevent or manage chronic disease.6

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Definitions and Research – Topics: Primary Prevention, Secondary Prevention, Wellness, Health Promotion, Population HealthExplain the difference between restorative care and preventive care.

Distinguish between primary and secondary prevention in a physical therapy plan of care

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Restoration vs Prevention

Restorative Care

• Services provided to older people on a short-term basis to restore their physical condition to a level which would allow them to return home with appropriate support.

Preventative Care

• This is aimed at promoting health, preserving health and restoring health when it is impaired and to minimize suffering and distress. There are various levels of prevention.

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Primary Prevention

The protection of health by personal and community-wide effects. Primary prevention involves measures provided to individuals to prevent the onset of a targeted condition.

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Secondary Prevention

•Measures that identify and treat asymptomatic persons who have already developed risk factors or preclinical disease, but in whom the condition is not clinically apparent. These activities are focused on early case- finding of asymptomatic disease that occurs commonly and has significant risk for negative outcome without treatment.

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Tertiary Prevention

•A process aimed at limiting the negative effects of an established disease.

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In what space do Physical Therapist’s Practice?

Restoration (Rehabilitation)

Primary Prevention

Maintenance

Secondary or Tertiary

Prevention25


Primary Prevention

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World Health Organization -Definition of Health

• Health is “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

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Well-being

• A dynamic state of physical, mental and social wellness; a way of life which equips the individual to realize the full potential of his/her capabilities and to overcome and compensate for weaknesses; a lifestyle which recognizes the importance of nutrition, physical fitness, stress reduction, and self responsibility.

• Well-being has been viewed as the result of four key factors over which an individual has varying degrees of control: human biology, social and physical environment, health care organization (system), and lifestyle

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What are Wellness and Health Promotion?

Wellness

• Defined as “the sense that one is living in a manner that permits the experience of consistent, balanced growth in the physical, spiritual, emotional, intellectual, social, and psychological dimensions of human existence.” J. Bezner

Health Promotion

• Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioural and environmental adaptations that will improve or protect health

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Wellness, Health Promotion Organizations

• APTA Council on Prevention, Health Promotion and Wellness

• Academy of Prevention and Health Promotion Therapies

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Population Health

• Population health is defined as a “concept of health” characterized by both objective and subjective determinants and health outcomes of a population (Kindig & Stoddart, 2003).

• The determinants and outcomes of population health are a function of three overarching domains of well-being: physical, psychological, and social well-being.

• Wellbeing is a subjective term that describes self-reported general life satisfaction and the positive and negative emotions associated with health status

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Population Health and Heart Disease

• New Ulm Project – Population based project in New Ulm, MN• Health care, community, and workplace interventions addressing multiple

levels of the social-ecological model designed to reduce modifiable CVD risk factors

• Blood Pressure <140/90; Low Density Lipoprotein cholesterol < 130mg/dL; Body Mass Index (BMI) < 30; smoking

• ANCHOR – A Novel Approach to Cardiovascular Health By Optimizing Risk Management (ANCHOR): Behavioural Modification in Primary Care Effectively Reduces Global Risk

• The improvements were largely realized through lifestyle modification rather than increased medication and the effect seems to be independent of primary care organization or reimbursement model.

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Diabetes and Population Health

• Clinical practice guidelines are key to improving population health; however, for optimal outcomes, diabetes care must be individualized for each patient. Thus, efforts to improve population health will require a combination of system-level and patient-level approaches.

• With such an integrated approach in mind, the American Diabetes Association (ADA) highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

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Social Determinants of Health (SDOH)Assessment – current lifestyle

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Six Ways to Talk about SDOH

1 Health starts—long before illness—in our homes, schools and jobs.

2 All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education or ethnic background.

3 Your neighborhood or job shouldn’t be hazardous to your health.

4 Your opportunity for health starts long before you need medical care.

5 Health begins where we live, learn, work and play.

6 The opportunity for health begins in our families, neighborhoods, schools and jobs.

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SDOH -Vulnerable Populations

Too many Americans don’t have the same opportunities to be as healthy as others

Americans who face significant barriers to better health

People whose circumstances have made them vulnerable to poor health

All Americans should have the opportunity to make the choices that allow them to live a long, healthy life, regardless of their income, education, or ethnic background

Our opportunities to better health begin where we live, learn, work and play

People’s health is significantly affected by their homes, jobs and schools

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SDOH – Health Disparities

• Raising the bar for everyone

• Setting a fair and adequate baseline of care for all

• Lifting everyone up

• Giving everyone a chance to live a healthy life

• Unfair

• Not right

• Disappointing (as in Americans should be able to do better, not let people fall through the cracks)

• It’s time we made it possible for all Americans to afford to see a doctor, but it’s also time we made it less likely that they need to

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SDOH - Poverty

Families who can’t afford the

basics in life

Americans who struggle

financially

Americans struggling to

get by

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SDOH – Low-income workers and families

People who work for a living and still can’t pay their rent

Hard-working Americans who have gotten squeezed out of the middle class in tough times

Families whose dreams are being foreclosed

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SDOH - The elderly population and their families, nursing homes and elder care

Our aging parents and

grandparents Our elders Elders

Caring for people as they age

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SDOH -Refugees and immigrants including children

People seeking a new home in America

Children caught between two worlds

From undocumented immigrants to productive, tax-paying American citizens

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SDOH – Mental health or illness, including young people

It’s just as dangerous and debilitating as any other chronic disease

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http://www.countyhealthrankings.org/app/new-jersey/2018/measure/factors/70/map 48

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Access to Exercise Opportunities

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Obesity, Metabolic Syndrome, Non-communicable diseases

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Obesity

• During 2009–2010, more than one-third of adults, or about 78 million people, were obese (defined as body mass index [BMI] ≥30 kg/m2).

• Nearly one of five youths aged 2–19 years was obese (BMI ≥95th percentile).

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Where is the population’s

health headed?

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Prevalence of Self-Reported Obesity Among

U.S. Adults by State and Territory

Definitions

Obesity: Body Mass Index (BMI) of 30 or higher.

Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, calculated by using the adult’s weight in kilograms divided by the square of his or her height in meters.


2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Behavioral Risk Factor Surveillance System56

Prevalence¶ of Self-Reported Obesity Among U.S.

Adults by State and Territory, BRFSS, 2011¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

*Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%.
















Prevalence¶ of Self-Reported Obesity Among U.S. Adults

by State and Territory, BRFSS, 2015

Summary

No state had a prevalence of obesity less than 20%.

6 states and the District of Columbia had a prevalence of obesity between 20% and <25%.

19 states and Puerto Rico had a prevalence of obesity between 25% and <30%.

21 states and Guam had a prevalence of obesity between 30% and<35%.

4 states (Alabama, Louisiana, Mississippi, and West Virginia) had a prevalence of obesity of 35% or greater.

¶ Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011.

http://www.cdc.gov/obesity/data/prevalence-maps.html

Metabolic Syndrome

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http://www.cdc.gov/obesity/data/prevalence-maps.html


Metabolic Syndrome

• Risk Factors – Must have at least 3 factors to be diagnosed with Metabolic Syndrome

1. A large waistline. This also is called abdominal obesity or "having an apple shape."

2. A high triglyceride level (or you're on medicine to treat high triglycerides).

3. A low HDL cholesterol level (or you're on medicine to treat low HDL cholesterol).

4. High blood pressure (or you're on medicine to treat high blood pressure).

5. High fasting blood sugar (or you're on medicine to treat high blood sugar).

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Metabolic Syndrome

• Metabolic syndrome is becoming more common due to a rise in obesity rates among adults.

• In the future, metabolic syndrome may overtake smoking as the leading risk factor for heart disease.

• It is possible to prevent or delay metabolic syndrome, mainly with lifestyle changes.

• A healthy lifestyle is a lifelong commitment.

• Successfully controlling metabolic syndrome requires long-term effort and teamwork with your health care providers.

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Metabolic Syndrome (change in fitness & weight)

• Increasing aerobic fitness may reduce prevalence of metabolic Syndrome

• Of the 5 risk factors, all were significantly affected by increased aerobic fitness at 6 months and all but high triglycerides at 18 months

• Benefits of aerobic fitness• Improved BP• Improved waist circumference• Improved HDL cholesterol

• Interventions• At least 180 minutes of moderate intensity physical activity• Weight loss of at least 15 lbs at 6 months for those with BMI at least 25.2• Reduced sodium diet (DASH diet)

Crist LA, Champagne CM, Corsino L, Lien LF, Zhang G, Young DR. Influence of change in aerobic fitness and weight on prevalence of metabolic syndrome. Prev Chronic Dis 2012;9:110171

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Lifestyle Changes and Cholesterol

• Heart Healthy Diet - fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. You should also limit red meat and sugary foods and beverages. Many diets fit that pattern, including the DASH – short for Dietary Approaches to Stop Hypertension

• https://www.choosemyplate.gov/

• Get Moving – 40 minutes of aerobic exercise of moderate to vigorous intensity done three to four times a week is enough to lower both cholesterol and high blood pressure. Brisk walking, swimming, bicycling or a dance class are examples.

• https://go4life.nia.nih.gov/

• Avoid Tobacco Products• https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/

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https://www.choosemyplate.gov/

https://go4life.nia.nih.gov/

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/


Diabetes Type 2

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What is Diabetes?

• A group of metabolic diseases resulting in hyperglycemia

• Deficits in Insulin Secretion, Insulin Action or both

• “Chronic hyperglycemia associated with long-term damage, dysfunction and failure of various organs, especially eyes, kidneys, nerves, heart and blood vessels”


Prevalence of Diabetes

• Diabetes is the 7th leading cause of death in the United States (2013)

• 200,000 deaths annually

• More than 29 million people are estimated to have diagnosed or undiagnosed diabetes

• About 1 out of 11 people have diabetes• Long pre-symptomatic phase prior to diagnosis of type 2 diabetes

(T2D)

Prevalence of Prediabetes

• 86 million U.S. adults have prediabetes

• 9 out of 10 do not know they have prediabetes

• More than 1 in 3 have prediabetes

• Increases risk of developing type 2 diabetes, heart disease and stroke

• Prevention is key – modifiable risk factors

• Weight Loss, Increase Activity Level, Eat Healthy

• 15% to 30% will develop T2D within 5 years


Diabetes Trends

• From 1980 – 2012, the number of new cases of diabetes quadrupled

• 1.7 million new cases of diabetes diagnosed each year

• If current trend continues – 1 in 3 adults could have diabetes by 2050

• Diabetes Risk Tool: https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/am-i-at-risk/diabetes-risk-test/Pages/diabetes-risk-test.aspx

Disease Types

What are the types of diabetes?

• Type 1 Diabetes (5% of cases)

• Type 2 Diabetes (90% - 95% of cases)

• Gestational Diabetes

• Other types (1% - 5% of cases)• Medication induced, surgery, infections, pancreatic disease

https://www.niddk.nih.gov/health-information/health-communication-programs/ndep/am-i-at-risk/diabetes-risk-test/Pages/diabetes-risk-test.aspx


What is Type 1 Diabetes (T1D)?

• The pancreas does not make enough insulin so glucose cannot enter the cells to be used for energy

• Beta cells in the pancreas are destroyed resulting in limited capacity to making and releasing insulin

• Cell-mediated autoimmune destruction of β-cells of the pancreas• Rate of destruction is variable (more rapid in children and

adolescents than adults)

• Absolute insulin deficiency

Type 1 Diabetes (T1D)

• Insulin is a hormone that lowers blood glucose levels

• Formerly called Juvenile Onset Diabetes/Insulin Dependent Diabetes Mellitus

• Can develop at any age

• No known way of preventing it

• Insulin delivery

• Insulin pump, Insulin syringe, Insulin pen


Who Is at Risk for Diabetes Type 2?

• Increased age: increased risk

• History of gestational diabetes: increased risk

• Your mother/father/sister/brother have diabetes: increased risk

• Having a diagnosis of high blood pressure: increased risk

• Physically inactive: increased risk

• Overweight: increased risk

• Take the Diabetes Risk Test

• Available at the American Diabetes Association Website

• http://www.diabetes.org/are-you-at-risk/diabetes-risk-test/

Healthy People 2020

Recommended preventative care practices for those aged 18 and over diagnosed with Diabetes (2012)

• Dilated eye exam annually

• A1C at least two times per year

• Foot exam annually

• Daily self monitoring of blood glucose• Attended diabetes self-management class


Healthy People 2030

What is Type 2 Diabetes (T2D)?

Begins as Insulin Resistance whereby cells in the muscles, liver and fat tissue do not use

insulin properly

• Relative Insulin Deficiency

• Specific Etiology is unknown

• Autoimmune destruction of β-cells does not occur

• Most individuals are obese

• Obesity itself increases insulin resistance

• Often goes undiagnosed for many years as hyperglycemia develops gradually over time

• Early stages – classic symptoms of diabetes go unrecognized

• At risk for developing microvascular and macrovascular complications


Type 2 Diabetes (T2D)

• Insulin levels are often normal or high as β-cell function is normal

• Insulin secretion is defective and insufficient to compensate for insulin resistance

• Insulin resistance may improve with weight loss and/or pharmacological treatment

• Formerly called Adult Onset Diabetes/Non-Insulin Dependent Diabetes Mellitus

• Preventable with weight loss, increasing activity level and better eating habits

Insulin Resistance/Insulin Sensitivity

• Insulin resistance: normal amount of insulin results in subnormal biologic response

• Insulin sensitivity: relates to the ability to metabolize glucose, (improved glucose tolerance), improved insulin effects at lowering blood glucose levels


Etiology of Insulin Resistance

• Insulin resistance results from an increased supply of fatty acids (e.g., high energy intake,

obesity) and conditions in which the degradation/oxidation of muscular fatty acids is

impaired

• Insulin signals glucose transport into skeletal muscle via GLUT4 that translocate to cell

surface

• Increase glucose transport proportional to increase in translocated GLUT4

• Physical Inactivity results in decreased insulin sensitivity and reduced VO2 Max (reduced

physical capacity)

• Lower capillary density, decreased proportion of type 1 muscle fibers, higher glycolytic to

oxidative enzyme ratio

Trainability of Insulin Sensitivity

• Lifestyle intervention can prevent or halt the progression of T2D in people with impaired glucose tolerance

• Improvement in insulin sensitivity with exercise training

• Ten week aerobic exercise program – insulin stimulated uptake was improved by approximately 10%

• Physiologic changes – weight-loss, body composition modifications (decreased adipose tissue, alterations in body fat distribution and diminished abdominal adiposity) and changes in diet composition additionally contribute as well to the final outcome


Glucose Metabolism

• Plasma glucose concentration

• Rate of glucose entering the circulation (glucose appearance) balanced by the

rate of glucose removal from the circulation (glucose disappearance)

• Glucose appearance

• Intestinal absorption during feeding

• Glycogenolysis* – breakdown of glycogen to glucose in liver

• Gluconeogenesis* – formation of glucose from lactate and amino acids during

the fasting state in liver

• * Partly under control of Glucagon

Glucose Metabolism (cont.)

Primary Glucoregulatory Hormones

• Glucagon – promotes glucose appearance

• Secreted from pancreatic α-cells

• Insulin – promotes glucose disappearance

• Secreted from pancreatic β-cells

• Promotes glucose uptake by cells

• Amylin – Slows gastric emptying, reduces food intake and body weight, suppresses

postprandial glucagon secretion

• GLP-1 – Enhances glucose-dependent insulin secretion, reduces food intake and body

weight, slows gastric emptying, suppresses postprandial glucagon secretion, promotes

β-cell health


Diabetes related Hypo/Hyperglycemia

Hyperglycemia

• Abnormally high blood glucose level (BGL)

• Fasting BGL >130 mg/dl

• Postprandial >180 mg/dl (2 hours after

eating)

• Signs include high levels of sugar in the

urine, frequent urination, increased thirst,

sweet smelling breath and urine

• Diabetic coma – Ketoacidosis

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Benefits of Physical Activity Beyond Weight Control

• Lowers blood sugar• Lowers cholesterol• Improves blood pressure• Lowers stress/anxiety• Improves mood


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Activities of Daily Living

• Diabetics may develop vision loss and numbness in the feet that impair

balance

• Standing and walking may become difficult with imbalance

• Walking on uneven surfaces may become difficult

• Neuropathy may cause burning pain in feet

• Gait becomes abnormal with wide base of support

• Loss of normal protective sensation may lead to skin breakdown on the

lower legs especially the feet

• May need to use a cane or walker for safety


Frailty

• Generally, frailty can be defined as a physiologic state of decrease resistance to stressors that results from decreased physiologic reserves of multiple systems and causes vulnerability to adverse outcomes.

• No uniform definition amongst frailty researchers.

• Frailty Phenotype vs. Frailty Index

• Fried Phenotype: syndrome with 5 key domains for frailty –weakness, low energy, slowed walking speed, decreased physical activity, and weight loss.

• People with 3 or more of the 5 domains are considered frail.

• Rockwood’s Frailty Index: accumulation of deficits - ratio of the number of deficits relative to the number of domains assessed – initially 92 domains modified to 30 domains

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Frailty Vital Sign?

• Linkage between Frailty and Cardiovascular Disease• Common Risk Factors: obesity, smoking, sedentary lifestyle.

• Inflammatory process resulting in catabolic state – loss of muscle mass and change in muscle metabolism.

• Proxies of frailty• Gait speed

• Clinical Frail Scale

• FRAIL score – Fatigue, Resistance (ability to climb 1 flight of stairs), Ambulationf (ability to walk 1 block), Illness (greater than 5), loss of weight (>5%)

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Pathophysiology of Frailty

Source: Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clin Interv Aging. 2014;9:433-441. doi:10.2147/CIA.S45300.

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Frailty > Sarcopenia

Source: Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clin Interv Aging. 2014;9:433-441. doi:10.2147/CIA.S45300.

Anorexia, Sarcopenia, OsteopeniaIncrease clottingGlucose dysregulationImmune dysfunctionIncrease stress hormoneCognitive Impairment

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Frailty Stages • Based on Fried Phenotype

• Non-Frail – Score 0 (No Fried criteria present)

• Pre-Frail – Score 1 or 2 (1 or 2 Fried criteria present)

• Frail – Score 3 – 5 (3, 4, or 5 Fried criteria present)

• Conclusions• Frail people appeared to be older, were more likely to be female, were more

often unmarried or living alone, and had a lower level of education compared to their pre-frail and non-frail counterparts.

• The most preferable scores came from the non-frail group, and least preferable scores were from the frail group.

• For example: use of informal care: non-frail 3.9 %, pre-frail 23.8 %, frail 60.6 %

• GARS IADL-disability mean scores: non-frail 9.2, pre-frail 13.0, frail 19.7

Op het Veld LPM, van Rossum E, Kempen GIJM, de Vet HCW, Hajema K, Beurskens AJHM. Fried phenotype of frailty: cross-sectional comparison of three frailty stages on various health domains. BMC Geriatr. 2015;15:77. 94

Prognostic Value of Frailty

• Frailty phenotype - predictive of falls, disability, institutionalization, hospitalization and mortality

• Pre-frail individuals have a significantly higher risk of developing these adverse outcomes than non-frail people.

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Efficacy of Exercise Combating Frailty

“To date, exercise is the interventional modality that has most consistently shown benefit in treating frailty and its key components. Exercise has physiologic impacts on almost all organ systems, particularly musculoskeletal, endocrine, and immune systems.”

Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clin Interv Aging. 2014;9:433-441.

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Interventions Moving Forward

• Early identification – frailty may be modifiable

• Prehab before surgery

• Rehab after surgery focusing on strength and environmental modifications

• Caloric Restriction and Metformin to target “metabolic drivers” of aging

• Protein supplementation

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Pre-Frailty

• Increase reserve capacity and reduce the impact of potential stressors may therefore reduce the risk of becoming frail

• Multifactorial Intervention RCT• Weight Loss – Referral to Dietitian

• Exhaustion (fatigue) – Referral to psychiatrist or psychologist if Geriatric Depression Score (GDS) is high

• Grip weakness, slow walk time, low physical activity level – PT 20-30 minutes 6 x per week for 12 months following the Weight Bearing Exercise for Better Balance (WEBB) program, available at http://www.webb.org.

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Weight Bearing Exercise for Better Balance (WEBB) program

• Lower Limb Strengthening (hip and knee extensors, plantar flexors)• Resistance applied by body weight or by weighted vests or weight-belts as

appropriate• standing up from a chair,

• forward and lateral step-ups onto a block

• heel raises while standing on a wedge.

• Balance targeted with exercises performed while standing on a progressively narrowed base (feet together, tandem stance, single leg stance), stepping, walking and reaching.

• Progression of object height for forward and lateral step overs. Repeated for 1 minute.

99

http://www.webb.org/


Sarcopenia• Age-related decline of muscle mass, strength and function, is an

important topic in current research on aging.

• No clinical consensus definition of sarcopenia, includes:• measurement of muscle mass

• measurement of muscle strength or function

• Screening tools – traditional imaging tests and grip strength/gait speed

• Treatment• Resistance training combined with endurance training; 2–3/week; Resistance

training at high intensity, high volume, high velocity (power training)

• 25-30g of protein every meal, supplement if not achieved with diet alone

• Vitamin D 800 IU/day

• Testosterone and Creatine SupplementationDe SA, Petrovic M, Van DNN, Boeckxstaens P. Treating sarcopenia in clinical practice: where are we now? Acta Clin Belg. 2016;71(4):197-205.

100

Sarcopenia

101


Physical Stress Theory (PST)

• Changes in relative level of physical stress cause a predictable adaptive response in all biological tissue

• Tissue homeostasis occurs when tissue degeneration is equal to tissue production

102

PST

103


US Physical Activity Guidelines, Go 4 Life, Resources

104

2008 US Physical Activity Guidelines

• Key Guidelines for Adults

• All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

• For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate-and vigorous intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, and preferably, it should be spread throughout the week.

• For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate intensity, or 150 minutes a week of vigorous intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging in physical activity beyond this amount.

• Adults should also do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits.

105


2018 US Physical Activity Guidelines

• Being Developed at Present Time.

• Will be released in 2018.

• Proposed guidelines are available.

• Benefits of PA on prevention of CVD, Stroke, DMT2, Cancer, Cognition

106

Physical Activity Recommendations

Adults need at least:

• walking 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week or

• 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and

• weight training muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).

107

https://www.cdc.gov/physicalactivity/basics/glossary/index.htm#aerobic


National Institute on Aging at NIH

108

US Preventive Services Task Force (USPSTF)

Recommendation screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese

Clinicians should offer or refer patients with abnormal glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity (B recommendation)

Screen for glucose abnormalities

Rescreen every 3 years

Behavioral Interventions on healthful diet and physical activity –multiple contacts over extended periods

Screening and intervention for modifiable risk factors (smoking, high blood pressure, abnormal lipid levels, physical inactivity, overweight and obesity)


US Preventive Services Task Force

• Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults Without Known Risk Factors: Behavioral Counseling

• Release Date: July 2017

110

US Preventive Services Task Force

• Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Behavioral Counseling

• Release Date: August 2014

111


Community Preventive Services Task Force

• Combined diet and physical activity promotion programs

• Increased likelihood to revert to normoglycemia, improve diabetes and cardiovascular disease risk factors, including overweight, high blood glucose, high blood pressure, and abnormal lipid profile

• Decreased proportion of people who develop T2D by 11%

National Association Recommendations

• American Heart Association

• American Lung Association/Lung Foundation

• American Diabetes Association

113


American Heart

Association

114

AHA - Lifestyle Changes and Cholesterol

• Heart Healthy Diet - fruits, vegetables, whole grains, low-fat dairy products, poultry, fish and nuts. You should also limit red meat and sugary foods and beverages. Many diets fit that pattern, including the DASH – short for Dietary Approaches to Stop Hypertension

• https://www.choosemyplate.gov/

• Get Moving – 40 minutes of aerobic exercise of moderate to vigorous intensity done three to four times a week is enough to lower both cholesterol and high blood pressure. Brisk walking, swimming, bicycling or a dance class are examples.

• https://go4life.nia.nih.gov/

• Avoid Tobacco Products• https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/

115

https://www.choosemyplate.gov/

https://go4life.nia.nih.gov/

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/


American Lung Association/Lung Foundation

• Stretching

• Aerobic

• Resistance

• Exercising for about half an hour on 5 days a week performing activities such as walking or stationary cycling, can improve health

116

Diabetes Prevention Program (DPP)

Based on study performed by National Institute of Health (NIH) and the Centers for Disease Control and Prevention (CDC)

• Published in NEJM 2002

• Placebo vs. Metformin vs. Lifestyle Modification

• Greatest improvement in Lifestyle Modification Group (LMG)

• 5% of LMG developed T2D vs 11% of Placebo Group each year during study


DPP - Lifestyle Modification Group

Intensive training in diet, physical activity, and behavior modification

• Low calorie, low-fat diet

• Physical activity of moderate intensity for a minimum of 150 minutes a week

• 16 lesson curriculum during first 24 weeks

• Followed by usually monthly individual and group sessions with case manager

• Program goal of losing 7% of body weight

DPP - Diet Modification

• Initial focus – reducing total fat

• Reduced caloric intake emphasizing overall healthy eating

• Weeks later

• Caloric goals to achieve a 1-2 pound per week weight loss• Fat goals – grams per day (25% of calories from fat)

• Purpose of the diet modification was for weight reduction and not to maintain blood glucose

• Emphasis on self-monitoring


DPP - Activity Modification

Supervised Physical Activity sessions

• At least 2 times per week

• Attendance was voluntary

• Types of activities varied across centers (All led by DPP staff or personnel trained by DPP staff)

• Neighborhood group walks

• Enrolling in Cardiac Rehab Programs affiliated with the DPP clinical center

• Community Aerobic classes (e.g. YMCA, Wellness Centers)

• One to one personal training

DPP - Activity Recommendations

• Brisk walking – build up to 150 minutes per week

• Include short bouts (10-15 min.) and healthy lifestyle activities: climbing stairs and walking extra blocks from the bus stop


CDC DPP

• Program based on DPP Study from 2002

• Lifestyle change program

• Lifestyle coach deliver curriculum content

• Program focus on weight loss through diet modifications and increasing activity

• 16 Sessions – Months 1 – 6

• 15 Sessions – Months 7 – 12

CDC DPP

Session 5 explains the benefits of physical activity

• “It helps to control our blood glucose, weight, and blood pressure. It raises our “good” cholesterol and lowers our “bad” cholesterol. It helps prevent problems with our heart and blood flow. And, most importantly, for people with diabetes, it lowers the risk for heart disease and nerve damage.”


Diabetes Self-Management Education and Support (DSME/DSMS)

• Ongoing process of facilitating the knowledge, skill, and ability necessary for prediabetics and diabetics self-care

• Should address psychosocial issues

• Emotional well-being is associated with positive outcomes

• Critical times

• At diagnosis; Annual Assessment; when new complicating factors influence self-management; when transitions occur

DSME/DSMS

• Skill based approach that helps diabetics make informed self-management choices

• Disciplines involved in Diabetes Education

• Key Primary Instructors: Nurses, Dietitians, Pharmacists

• Other instructors: The Multidisciplinary team: Physicians, Psychologists and other Mental Health Specialists, Physical Activity Specialists (Physical Therapists, Occupational Therapists, and Exercise Physiologists), Optometrists and Podiatrists


DSME/DSMS (cont.)

Core Topics

• Describes the Diabetes Disease Process and Treatment options

• Incorporating nutritional management into lifestyle

• Incorporating physical activity into lifestyle

• Using medications safely and for maximum therapeutic effectiveness

• Developing personal strategies to promote health and behavior change

Core Topics

• Monitoring blood glucose and other parameters and interpreting and using the results for self-management decision making

• Preventing, detecting and treating acute complications

• Developing personal strategies to address psychosocial issues and concerns

126

ADA Standards of Medical Care 2015

Nutrition Therapy

• Nutrition therapy is recommended for all people with type 1 and type 2 diabetes as an effective component of the overall treatment plan

• Individuals who have prediabetes or diabetes should receive individualized medical nutrition therapy as needed to achieve treatment goals


ADA Standards of Medical Care (cont.)

Dietary Recommendations

• Evidence suggests there is no ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes

• Therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals

ADA Standards of Medical Care (cont.)

Psychosocial Assessment and Care

• Psychosocial screening/follow-up: attitudes, medical management/outcomes expectations, affect/mood, quality of life, resources, psychiatric history

• Routinely screen for psychosocial problems: depression, diabetes-related distress, anxiety, eating disorders, cognitive impairment


Blood Sugar Testing

• Tight control means getting as close to a normal (nondiabetic) blood glucose level as you safely can

• Levels between 70 and 130 mg/dl before meals, and less than 180 two hours after starting a meal,

• A1C level less than 7 percent

• Set your goals with your doctor

ADA Standards of Medical Care

Physical Activity for Adults with Diabetes

• At least 150 min per week of moderate-intensity aerobic activity (50–70% of maximum heart rate), over at least 3 days per week with no more than 2 consecutive days without exercise

• Moderate intensity means that you are working hard enough that you can talk, but not sing, during the activity

• Vigorous intensity means you cannot say more than a few words without pausing for a breath during the activity

• Reduce sedentary time, particularly by breaking up extended amounts of time (>90 min) spent sitting

• If not contraindicated, adults with T2D should perform resistance training at least twice weekly


ADA Recommended Activity

Aerobic exercise

• 30 minutes of moderate-to-vigorous intensity aerobic exercise at least 5 days a week or a total of 150 minutes per week

• Moderate intensity means that you are working hard enough that you can talk, but not sing, during the activity

• Vigorous intensity means you cannot say more than a few words without pausing for a breath during the activity

ADA Recommended Activity (cont.)

Aerobic exercises

• Brisk walking

• Bicycling

• Swimming

• Tennis • Jogging/running

• Hiking

• Rowing



Strength training

• At least 2 times per week in addition to aerobic activity• Lowers blood glucose and improves insulin sensitivity

• Maintains or increases muscle strength and bone strength, reducing your risk for osteoporosis and bone fractures

• The more muscle mass you have, the more calories you burn – even when your body is at rest


Strength training

• Weight machines or free weights at the gym

• Using resistance bands

• Lifting light weights or objects like canned goods or water bottles at home

• Exercises that use your own body weight to work your muscles (examples

are pushups, sit ups, squats, lunges, wall-sits and planks)

• Yoga

• Pilates

• Classes that involve strength training


Exercise Considerations

• Retinopathy – vigorous aerobic or resistive exercise may increase risk of triggering vitreous hemorrhage or retinal detachment

• Peripheral neuropathy – increase risk of skin breakdown/infection and Charcot joint destruction

• Ensure proper foot wear and foot examination

• Autonomic neuropathy – increase risk of exercise-induced injury or adverse event through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision, higher susceptibility for hypoglycemia

Small Group – Current Practice Integration of Lifestyle assessment

137


Small Group

• Current lifestyle assessment you utilize.• For example, Occupation

• Do you obtain physical activity level?

• Do you obtain any biopsychosocial factors impacting patient/client?

138

Bio-Psychosocial Model (ICF)

• Includes physical, social, and other environmental factors that interact with an individual’s health conditions and other characteristics to produce outcomes

• activity (defined as the execution of a task or action by an individual – level of the individual)

• participation (defined as an individual’s involvement in a life situation – level)• Appears to be more relevant to quality of life

139


ICF

• Shift in thinking from emphasizing people’s disability to focusing on their level of health

• Describes an interaction of physical, social, and environmental factors with an individual’s health conditions that produces outcomes of interest for physical therapists.

• Recognizes the role of the environment in determining an individual’s ability to participate in society.

140

International Classification of Function, Disability and Health (ICF)

141


ICF Checklist Environmental Factors

ICF Checklist © World Health Organization, September 2003

142

APTA—Providing PT in the Home (2014)

ICF Health Conditions—PT Considerations(Figure 7.1)

• Past medical/surgical history

• Primary and secondary diagnoses

• Prior level of function

143



ICF Body Functions and Structures—PT Considerations(Figure 7.1)

• Aerobic capacity

& endurance

• Cranial/peripheral

nerve & reflex

integrity

• Motor

function/muscle

performance

• Anthropometric

measures

• Gait & locomotion • Neuromotor

development and

sensory

processing

• Balance • Integumentary

integrity

• Mental functions

• Circulation • Joint

integrity/mobility

and ROM

• Posture/body

mechanics

144


ICF Activity Limitations—PT Considerations(Figure 7.1)

• Learning/applying knowledge

• Communication

• Mobility

• Self-care, home management, and domestic life (ADL/IADL)

145



ICF Participation Restrictions—PT Considerations(Figure 7.1)

• Community (grocery shopping, pharmacy, physician

appointments

• Leisure integration (lunch with friends, swimming, hiking)

• Social (attending church, family reunions)

• Work (employment, yard work)

• Education (attending school)

146


ICF Environmental Factors—PT Considerations(Figure 7.1)

• Products/technology (food, medicines, assistive devices,

ramps, grab bars, and other home safety modifications)

• Climate (temperature), lighting, fire safety

• Support, relationships, and access to health services (both

good and bad)

• Attitudes (of family, caregivers, health care professions, but

does not include the individual’s attitude)

• Access and need for community services, transportation, etc

• Other environmental factors (barriers that may limit access

to job, school, recreation) 147



ICF Personal Factors—PT Considerations (Figure 7.1)

• Lifestyle/habits

• Socioeconomics

• Education level

• Life events

• Race/ethnicity

• Sexual orientation

• Emotions/depression148

Intervention - Physical Activity Vital Signs and Exercise Prescription, diet

149


Call to Action • – Physical Activity Vital Sign (PAVS) – American College of Sports

Medicine and Kaiser Permanente• ~50% of deaths are attributed to unhealthy lifestyle behaviors such as a poor

quality diet, cigarette smoking, stress, and physical inactivity

• “The health care team is uniquely positioned to address the importance of a healthy lifestyle, including physical activity, in the prevention and treatment of disease and disability. Based on existing evidence, increasing physical activity is a cost-effective, first-line intervention for many chronic diseases.”

• Sallis RE, Matuszak JM, Baggish AL, et al. Call to action on making physical activity assessment and prescription a medical standard of care. Curr Sports Med Rep. 2016;15(3):207-214.

• Article did not mention physical therapy or occupational therapy

150

Physical Activity Vital Sign (PAVS)

Patient Report Measure

1. On average, how many days a week do you perform physical activity or exercise?

2. On average, how many total minutes of physical activity or exercise do you perform on those days?

days/week X minutes/day = min/week (PAVS)

3. Describe the intensity of your physical activity or exercise:

Light = casual walk Moderate = brisk walk Vigorous = jogging

151


Five A’s

•Ask – PAVS

•Advise – Encourage physical activity

•Assess readiness to increase physical activity

•Assist with treatment plan

•Arrange follow-up

Sallis RE, Matuszak JM, Baggish AL, et al. Sallis RE, Matuszak JM, Baggish AL, et al. Call to action on making physical activity assessment and prescription a medical standard of care. Curr Sports Med Rep. 2016;15(3):207-214

152

HF-ACTION Trial• RCT – N= 2331. Two groups, control and exercise group• Exercise training group

• 11% reduction in all-cause mortality/hospitalizations• 15% reduction in cardiovascular mortality/HF hospitalizations• Improved QOL Kansas City Cardiomyopathy Questionnaire

• Exercise Prescription utilized a single approach to exercise• moderate intensity, continuous aerobic exercise, 3 times per week supervised for 30

minutes

• Supervised 36 sessions, with an individualized exercise prescription on the basis of cardiopulmonary exercise testing (CPX).

• Halfway through this training period, patients received, at no cost, a home treadmill or stationary bicycle and a heart-rate monitor for personal use.

• They were instructed to exercise 5 times per week at moderate intensity for 40 min.

Forman DE, Sanderson BK, Josephson RA, Raikhelkar J, Bittner V, American College of Cardiology’s Prevention of Cardiovascular Disease Section. Heart Failure as a Newly Approved Diagnosis for Cardiac Rehabilitation: Challenges and Opportunities. J Am Coll Cardiol. 2015;65(24):2652-2659

153


Functional Status and Re-hospitalization Risk• Patient’s with COPD who were non-ambulatory at discharge were more

than twice as likely to be re-admitted in 30 days compared to patients able to ambulate 50 feet.

• Patient’s able to ambulate < 50 feet were not more likely than those that could ambulate >50 feet to be re-admitted.

• Risk of re-hospitalization within 30 days increased with:• Hx of prior hospitalizations within 12 months• New Prescription for Oxygen at Discharge• Presence of anemia at admission• Chronic Pain• Visit to ED or an observational stay within 30 days of DC and prior to a readmission

that occurred.• Length of stay longer than 13 days

Nguyen HQ, Rondinelli J, Harrington A, et al. Functional status at discharge and 30-day readmission risk in COPD. Respir Med. 2015;109(2):238-246. 154

Therapy Interventions for COPD

• Patient education in symptom management during exercise (especially breathlessness)

• Flat walking track (preferably indoor and air-conditioned), resistance bands, hand weights and pulse oximeter

• Assessment: Six-minute walk test (6MWT), dyspnea scale, pulse oximeter, device to measure blood pressure, spirometer, disease-specific quality of life questionnaire (e.g., St. George’s Respiratory Questionnaire or Chronic Respiratory Disease Questionnaire).

Hoffmann TC, Hons B, Maher CG, et al. Prescribing exercise interventions for patients with chronic conditions. Cmaj. 2016;188(7):510-518

155


Exercise Prescription for COPD

• Prescriptive elements• Intensity.

• Duration.

• Frequency.

• Type (interval or continuous).

• Mode (e.g. walking, cycling, arm exercise).

• Progression.

• Based on individual results from tests of exercise endurance capacity and strength.

156

Exercise Prescriptions Examples

Impairment Mode Intensity Type Duration Frequency

Endurance Walking trainingGround based

5-6 on Rate of Perceived Exertion Scale (RPE)

Continuous or Interval

30 minutes 5 x per week

LE ExtensorStrength

Closed Chain Leg Press

80% of 1 Rep Max

Starting with Red theraband –100 % elongation

Continuous or Interval

1 set to achieve 80% of 1 RM

Between 8-25 reps

3 x per week

Adapted from pulmonaryrehab.com 157


Exercise Prescription for Diabetes/Prediabetes

• Mode: Aerobic exercise, resistance training and a combination of both are the most effective for glucose control.

• Equip needed:

• Aerobic exercise: good walking shoes, aerobic equipment if desired (treadmill, stepper, bike, etc.).

• Resistance training: free weights or machine-based training. Low-intensity training with bands or no equipment is not effective.

• A glucose-monitoring device, blood pressure cuff and easy access to high glucose drinks and snacks is recommended.


• Aerobic exercise should consist of large-muscle activities (e.g., walking, running, cycling and swimming) tailored to preferences and comorbidities.

• 3–5 sessions per week for aerobic exercise; continue indefinitely

• Resistance training (include multijoint exercises and large muscle groups) may include free weights or machine-based training

• 2–3 sessions per week for resistance training

• Schedule details: Exercise may need to be timed to coincide with peaks of glycemia postprandially and should not be undertaken after insulin or oral hypoglycemic administration without eating a meal beforehand.

• Shorter sessions may be accumulated across the day to achieve the full duration.

• No more than two consecutive days without exercising. • Aerobic and resistance training may be done on separate days, which may

improve efficacy and feasibility.



Aerobic exercise:

• Accumulate 150 minutes of moderate intensity using rated perceived exertion of 5-6 Modified Rating of Perceived Exertion (RPE) Scale) in 3–5 sessions per week; OR 75 minutes of vigorous intensity using perceived exertion of 7-8 Modified RPE Scale) in 3–5 sessions per week.

Resistance training:

• Moderate to vigorous intensity (rated perceived exertion of 5-8 on a Modified RPE Scale), 8–10 exercises; 2–4 sets of 8–10 repetitions per set) in 2–3 sessions per week

Strength Training in Older Adults

• Muscle Strengthening• Intensity

• At 60% of 1 RM (minimum recommended intensity)• 15 reps at 3-4 in modified RPE scale

• At 80% of 1 RM• 10 reps at 5-7 on modified RPE scale

• Frequency – 2-3 x per week allowing 24-48 hours of rest in between

• Duration – 12-16 weeks

• 10 RM method documented in white paper.

Avers D, Brown M. White paper: Strength training for the older adult. J Geriatr Phys Ther. 2009;32:148-152, 158

161


https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm

Rate of Perceived Exertion

• Omni Rate of Perceived Exertion (RPE) Scale

Number Word Descriptors

0 Extremely easy

1

2 Easy

3

4 Somewhat easy

5

6 Somewhat hard

7

8 Hard

9

10 Extremely hard

Utter, et al. Med Sci Sports Exerc. 2004

163


High Intensity Resistive Training

• Is it safe?

• Baseline T scores = -1.87 Lumbar Spine and -2.01 Femoral Neck

(-1 to-2.5 osteopenia, -2.5 or lower is osteoporosis)

• Liftmor Trial – Study on people with Osteoporosis• No injuries• Exercises included at 80-85% 1RM• Deadlift• Squat• Overhead Press• Impact Loading – jumping chin ups with drop landings.

Weight Management

For overweight or obese individuals with T2D or are at risk

• Reduce energy intake while maintaining healthful eating pattern to promote weight loss

• Follow Dietary Guidelines for Americans, 2010

• MyPlate/DPP • http://www.choosemyplate.gov/


Dietary Approaches to Stop Hypertension (DASH)

• Diet rich in fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish, poultry, beans, seeds, and nuts.

• It also contains less sodium; sweets, added sugars, and beverages containing sugar; fats; and red meats than the typical American diet.

• This heart-healthy way of eating is also lower in saturated fat, trans fat, and cholesterol and rich in nutrients that are associated with lowering blood pressure—mainly potassium, magnesium, calcium, protein, and fiber.

For Diabetes: Basic Carbohydrate Counting

• Carbohydrates are the foods that break

down into glucose (sugar) and have the

greatest effect on raising blood glucose

• Avoid eating excessive amounts of carbs

• Carb containing foods are starches, such

as bread and rice; fruit and fruit juice; and

milk, yogurt, and sweet foods

• Your recommended carbohydrate intake

varies depending on your height, weight,

age, and activity level

Types of Carbohydrates

• Starches – complex carbohydrates• Peas, corn, potatoes• Rice, barley, Oats

• Sugars• Many names – sucrose, high fructose corn

syrup, agave nectar,

• Fiber• From beans and legumes, fruits and

vegetables, especially with edible skin, whole grains, nuts

167


Mediterranean Diet and Frailty• Mediterranean Diet inversely associated with frailty [OR = 0.30 (95%

CI: 0.14, 0.66)]

• A higher adherence to a Mediterranean-style diet at baseline was also associated with a lower risk of low physical activity (OR=0.62;95%CI: 0.40, 0.96) and low walking speed [OR=0.48 (95%CI: 0.27, 0.86)] but not with feelings of exhaustion and poor muscle strength.

• Protective associations have also been reported for aging- associated health outcomes, including cognition, dementia, and mobility

• Mediterranean diet emphasizes plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts. It replaces butter with healthy fats, such as olive oil and canola oil, and uses herbs and spices instead of salt to flavor foods. Red meat is limited to no more than a few times a month, while fish should be on the menu twice a week.

168

169


Apply use of the physical activity vital sign as an assessment tool within the physical therapy examination.

170

Use of PAVS/Wearable Trackers

• Establish Baseline of physical activity via – patient report or wearable

• Establish goals to increase by 10% within time frame.

• Ask patient/client – how likely are you to be able to do…?

• If less than 7 ask, what would it take to get you to a 10?

• Recommendations 10,000 steps per day.

171


Wellness PlanDesign a wellness/prevention treatment plan

incorporating dosing and intensity parameters into the interventions prescribed.

172

Case Scenario – Health Promotion/Wellness• Client is 75 year old male, Hx of OA R knee, HTN, high chol. with BMI

of 32 seen in your office for a well visit. Vitals: BP-134/80, HR-70, RR-18.

• Meds – Metoprolol, Tylenol, Simvastatin

Test and Measure Normative Data

Hand Grip Dynamometry R – 30 kgL – 29 kg

33. kg31.1 kg

Chair Rise Test – 30 sec Chair stand Test – 5 reps

11-17 reps

Two Minute Step Test – 55 reps 73-109 reps

Timed Up and Go – 12 seconds 13.5 seconds cut off for fall risk

Usual Gait Speed – 0.88 M/S 0.954 M/S

173


Exercise Prescription for a Wellness Plan

ImpairmentCategory (Strength, aerobic, balance, etc)

Mode (Open chain.closedchain/pool)

Intensity (on RPE scale)

Type (Continuous or Interval)

Duration (Time) or sets (% RM)

Frequency (x per week)

174

Conclusion and Question/Answer

Thank You

Email: [email protected]

Twitter: @kenmpt

175

mailto:[email protected]


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Communicable Disease Efforts. Henry J Kaiser Fam Found. 2017:1-8. http://files.kff.org/attachment/fact-sheet-The-US-Government-and-Global-Non-Communicable-Disease-Efforts%0Ahttp://kff.org/global-health-policy/fact-sheet/the-u-s-government-and-global-non-communicable-diseases/.

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4. Nguyen HQ, Rondinelli J, Harrington A, et al. Functional status at discharge and 30-day readmission risk in COPD. Respir Med. 2015;109(2):238-246. doi:10.1016/j.rmed.2014.12.004.

5. Sallis RE, Matuszak JM, Baggish AL, et al. Call to action on making physical activity assessment and prescription a medical standard of care. Curr Sports Med Rep. 2016;15(3):207-214. doi:10.1249/JSR.0000000000000249.

176

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7. Review C. Behavioral Counseling to Promote a Healthful Diet in Adults Without Cardiovascular Risk Factors. 2017;318(2):167-174. doi:10.1001/jama.2017.7171

8. De SA, Petrovic M, Van DNN, Boeckxstaens P. Treating sarcopenia in clinical practice: where are we now? Acta Clin Belg. 2016;71(4):197-205. doi:10.1080/17843286.2016.1168064.

9. Classification I. Standards of Medical Care in Diabetes d 2017. 2017;40(January 2017). doi:10.2337/dc17-S001

10. Bezner JR. Promoting Health and Wellness: Implications for Physical Therapist Practice. Phys Ther. 2015;95(10):1433-1444. doi:10.2522/ptj.20140271

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Improving Health through lifestyle modification