diabetes and exercise exercise referral cpd pure training and development © 2014

DIABETESAND EXERCISE

EXERCISE REFERRAL CPD

Pure Training and Development © 2014

Tutor – Who am I?

COPYRIGHT © PURE TRAINING AND DEVELOPMENT

• Emma Howard• Creator of these workshops and seminars • 5 years experience in Exercise Referral Industry• Passionate about improving the health and

wellbeing of your community

Learner Support

• Home study does not mean no support

• Please call us on 03302231302

• Email us on

[email protected]

• Supporting materials in Dropbox

• If you would like this training in a different format

please contact us


mailto:[email protected]

Learning Objectives

• Explore the aetiology of obesity, metabolic syndrome and diabetes

• Understand the recent prevalence statistics of obesity and diabetes in the UK

• Identify the benefits of physical activity and exercise in risk reduction and management of the condition

• Identify an exercise prescription framework• Understand basic nutritional advice • Recognise and apply health and safety considerations


Let’s get ready

Pure Training and Development © 2014

AETIOLOGY of Obesity

• Excess accumulation of body fat which becomes detrimental to health

• Often determined using the BMI scale (kg/m2)• Issues related to BMI

• The cause is attributed to energy imbalances• Genetics can also be a determinant but rare

• Why some people overeat (hyperphagia) more than others is inconclusive but here are some likely causes:


• Varied hormonal regulation of appetite • Leptin deficiency/resistance is an example • Regulated by the hypothalamus• Leptin is secreted from adipocytes • Adipocytes store energy as fat • When cells are full, leptin is secreted to supress

hunger• When cells are low, less leptin is secreted and

enhanced feelings of hunger will occur



• Obese people tend not to be deficient in leptin but insensitive to its effects (Considine et al, 1996)

• Other hormones involved in appetite regulation may be involved• Peptide (suppresses appetite) • Ghrelin (enhances appetite)• Obestatin (opposes ghrelin)

• For more information further reading is recommended

• Hypothyroidism (thyroid gland not producing enough thyroxine)

• Obesity is more commonly due to consuming too many calories



(Buckley, 2008)

Prevalence in the UKObesity

NHS stats for Obesity in England for 2011/2012:• 24% of adult men and 26% of women were obese in 2011

compared to 13% of men and 16% of women in 1993 • 41% of adult men and 33% of women were overweight in

2011• 34% of adult men and 39% of women had a normal BMI• 9.5% of 4-5 year old children were obese during 2011-2012

Health outcomes:• In 2011, 53% of obese men and 44% of obese women were

found to have high blood pressure• During 2011-12 there were 11,736 hospital admissions due

to obesity – this over 11 times higher than during 2001-02

Health and Social Care Information Centre (2013)


Connection between Obesity & Type 2 diabetes

• Obesity is closely linked to increasing risk of type 2 diabetes

• ‘Obesity is believe to account for 80-85% of the risk of developing type 2 diabetes’ (Diabetes.co.uk)

• ‘Recent research suggests that obese people are 80 times more likely to develop type 2 diabetes than other with a BMI of 22 and less’ (Diabetes.co.uk)

• Theories suggest increased levels of fat tissues cause a reduction in insulin resistance

• Suggested through inflammatory response disrupting the function of insulin responsive cells

• Obesity is responsible for pre diabetes COPYRIGHT © PURE TRAINING AND DEVELOPMENT

AETIOLOGY of Pre Diabetes & Metabolic Syndrome

• Pre diabetes is on the border of becoming diabetic • Higher than normal glucose levels

• Metabolic syndrome refers to a group of problems which an individual may suffer from, including • Dyslipidaemia • Glucose intolerance• Hypertension• Central adiposity

• View the IDF for metabolic syndrome worldwide definition (handout)

• Increased likelihood of CVD or type 2 diabetesCOPYRIGHT © PURE TRAINING AND DEVELOPMENT

• International Diabetes Federation (2005) stated• People with metabolic syndrome are twice as

likely to die from, and three times as likely to have a heart attack or stroke compared with people without the syndrome

• People with metabolic syndrome have a five-fold greater risk of developing type 2 diabetes

AETIOLOGY of Pre Diabetes & Metabolic Syndrome


Break Time

Take a 10-15 minute break.


• Diabetes mellitus is a metabolic disorder caused by chronic hyperglycaemia

• Results from insufficient levels of the hormone insulin which is released from the pancreas

• Two forms: Type 1 (juvenile onset) Type 2 (adult/lifestyle)

• Hyperglycaemia is a characteristic of both forms of diabetes, however, the cause differs between the two

AETIOLOGY of Diabetes


AETIOLOGY of Diabetes• Insulin is responsible for signalling glucose

storage in the liver (glucose synthesis), muscle (glucose

synthesis) and adipocytes (glycerol synthesis).

Type 1 Diabetes

• Deficient secretion of insulin from pancreas• Caused by the insulin B-cells in the pancreas

being destroyed (Beta-cells make insulin)• Body therefore does not produce enough insulin



Type 1 Diabetes

• Subsequently causes hyperglycaemia • Hyperglycaemia can damage blood vessels and

nerves• Can result in further conditions being diagnosed

• Treated by insulin injections• Eat healthy balanced meals


Type 2 Diabetes

• Insulin resistance - resistant to effects of insulin• Impaired production can also occur in type 2• Liver, muscles and fat cells are not as responsive to

insulin • Therefore beta cells have to work harder to

produce more insulin• Exercise & diet• Medication aims to enhance insulin sensitivity



Country Prevalence Number of people

England* 6 per cent 2,703,044

Northern Ireland 5.3 per cent 79,072

Scotland 5.6 per cent 252,599

Wales 6.7 per cent 173,299

Prevalence in the UKDiabetes

http://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-prevalence-2013/

The Quality and Outcomes Framework (QOF) reported in 2012 the number of people diagnosed with diabetes was as follows:


Associated Consequencesof Diabetes

High levels of circulating glucose can be associated with:• Hypoglycaemia and hyperglycaemia• Retinopathy (eyes)• Nephropathy (kidneys)• Peripheral vascular disease (atherosclerosis)• Peripheral neuropathy (nerve damage)• Diabetic coma


Physical Activity

In the risk reduction & management of the condition


PHYSICAL ACTIVITYRisk Reduction

What do we know?• Relationship between physical inactivity and

obesity• Link between obesity and type 2 diabetes• Little to no evidence to suggest that physical

activity can reduce the risk of type 1 diabetes• Strong evidence to suggest physical activity can

reduce the risk of type 2 diabetes


• Increasing physical activity can reduce the risk of type 2 diabetes.

• Protective effects observed in subjects with an excessive BMI and elevated glucose levels. • Regulation of body weight• Reduction of insulin resistance• Improved glycaemic control• Controlled hypertension

• Physical activity and weight control are critical factors in diabetes prevention in subjects with both normal and impaired blood glucose regulation. (Hu et al, 2004)



Epidemiological studies suggest:• 30-50% reduced risk for physically active

individuals of developing type 2 diabetes compared to sedentary people

• Physical activity confers a similar risk reduction for coronary heart disease.

• 30 minutes a day of moderate physical activity has been proven to help reduce the likelihood of type 2 diabetes

(Bassuk & Manson, 2005)



• ACSM state studies are now well established • Structured interventions combining PA and modest

weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations (ACSM, 2010).

• Additionally positively affecting lipids, blood pressure, cardiovascular events, mortality, and quality of life.

(ACSM, 2008)

PHYSICAL ACTIVITYRisk Reduction & Management of Condition


PHYSICAL ACTIVITYManagement of Condition

• Exercise as a form of intervention is successful at reducing weight loss

• Exercise assists insulin in glucose clearance through enhancing metabolism

• Exercise improves sensitivity of insulin receptors• Reduces risk of associated conditions• Many other health benefits


A systematic review found:Structured exercise training that consists of aerobic

exercise, resistance training, or both combined is associated with HbA1c reduction in patients with type 2 diabetes. Structured exercise training of more than 150

minutes per week is associated with greater HbA1c declines than that of 150 minutes or less per week.

Physical activity advice is associated with lower HbA1c, but only when combined with dietary advice.

(Umpierre, D et al 2011)

PHYSICAL ACTIVITYManagement of Condition


Break Time

Take a 10-15 minute break.


EXERCISE PRESCRIPTIONKey Objectives

• Increase insulin sensitivity• Decrease body fat• Decrease cardiovascular risk• Increase quality of life


• 5 days or more per week (more has proven effective) (Umpierre, D et al 2011)

• Moderate intensity (Bassuk & Manson, 2005; ACSM, 2010)

• 30 minutes a day 5 days a week or more (Bassuk & Manson, 2005)

• Or 150 minutes or more per week (ACSM, 2010; Umpierre, D et al 2011)

EXERCISE PRESCRIPTIONFrequency, Intensity & Time


• Cardiovascular exercises • Starting with ADL exercise i.e. walking & cycling

(Frank,et al, 1999; Hu et al, 1999)

• Progress to gym based modes & swimming etc• Be aware of risk associated with hypoglycaemia attack

and drowning

• Resistance exercises• Machines and moves on to free weights

EXERCISE PRESCRIPTIONModes of Exercise


• The prevalence of hyperglycaemia following a single session of resistance or endurance exercise substantially reduced during the following 24 hours.

• This applied to those with IGT and type 2 diabetic patients being insulin-treated and non-insulin-treated

• Resistance- and endurance-type exercise can be integrated in exercise intervention programmes designed to improve glycaemic control.

(Van Dijk et al, 2012; Umpierre, D et al 2011)

EXERCISE PRESCRIPTIONModes of Exercise - Evidence


Symptoms of Diabetes Mellitus Hypoglycaemia (low) Hyperglycaemia (high)

Grey colour (pallor) Intense thirst

Cold, clammy skin Excessive urination

Trembling/shakes Dehydration

Slurred speech Sweet smelling breath

Excessive sweating Drowsiness

Dizziness Fatigue

Fainting Decreased energy

Blurred vision High levels of ketones in the urine

Appearing drunk (lack of motor control)

Mood changes (i.e. anger, irritable)


• Observation • Signs of hypoglyceamia

• Talk test• Coherence, slurred speech

• RPE• Impaired cognition

• HR

EXERCISE PRESCRIPTIONMethods of Monitoring


• Unstable glucose levels• Active retinal haemorrhage • Excessive exercise duration can cause

hypoglycaemia • Try and schedule exercise at same time of day• Do not exercise within 3 hours of intended sleep

EXERCISE PRESCRIPTIONContraindications & Considerations


• Avoid valsalva manoeuvre• Do not exercise areas of the body used for

injections (at least one hour)• Ensure client/you have carbohydrate snack

EXERCISE PRESCRIPTIONContraindications & Considerations


Nutritional Advice


Nutritional Advice

• Same advice provided to the general population• Emphasise healthy balanced meals• Encourage high fibre, low glycaemic index sources

of carbohydrates such as fruit, vegetables, wholegrains and pulses; include low-fat dairy products and oily fish; and control the intake of foods containing saturated and trans fatty acids (NICE, 2008)

• Eat regular meals • Keep hydrated • Should be individualised for the client


Nutritional Advice Further information can be found at:www.diabetes.co.uk/diet/nhs-diet-advice.html

http://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/Healthy-eating--herbal-supplements/

Documents to download and save:http://www.diabetes.org.uk/upload/9831%20Eating%20Well%20Type%202.pdf


http://www.diabetes.co.uk/diet/nhs-diet-advice.html





http://www.diabetes.org.uk/upload/9831%20Eating%20Well%20Type%202.pdf



Nutritional Advice


Summary points• Two types of diabetes• Type 1 is due to an insulin deficiency• Type 2 is due to insulin resistance• 2,703,044 in England in 2012 were reported to have

diabetes• Strong evidence to suggest physical activity can reduce

the risk of developing type 2 diabetes• Structured interventions combining PA and modest

weight loss have been shown to lower type 2 diabetes risk by up to 58% in high-risk populations (ACSM, 2010).

• Physical activity can reduce severity of cardiovascular disease associated with type 2 diabetes


• 30 minutes a day of moderate physical activity has been proven to help reduce the likelihood of type 2 diabetes (Bassuk & Manson, 2005)

• Combination of cardiovascular exercise and resistance training is effective

• Nutrition programmes and physical activity in combination are central to the management and prevention of type 2 diabetes. Combined they help treat the associated glucose, lipid, BP control abnormalities, as well as aid in weight loss and maintenance. (ACSM, 2010)

• Be aware of contraindications and co-morbidities associated with diabetes

Summary Points


Recommended Reading


Useful Websites

• http://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/

• http://www.type2diabetesandme.co.uk/lnt/Login.aspx?ts=635252416594354915

• http://guidance.nice.org.uk/CG66 • http://

www.bupa.co.uk/individuals/health-information/health-news-index/2013/The-obesity-and-type-2-diabetes-connection

Since these pages are regularly updated you may encounter an error in opening them up. You are recommended to go to the original source directly (i.e. diabetes.org.uk).


http://www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes/



http://www.type2diabetesandme.co.uk/lnt/Login.aspx?ts=635252416594354915

http://www.type2diabetesandme.co.uk/lnt/Login.aspx?ts=635252416594354915

http://guidance.nice.org.uk/CG66

http://guidance.nice.org.uk/CG66

http://www.bupa.co.uk/individuals/health-information/health-news-index/2013/The-obesity-and-type-2-diabetes-connection




References• Bassuk, S.S., & Manson, J.E. (2005). Epidemiological evidence for the role of physical activity in reducing risk of type 2

diabetes and cardiovascular disease. Journal of Applied Physiology, 99, 1193-1204.

• Buckley, J. (2008). Exercise Physiology in Special Populations. China: Churchill Livingstone Elsevier.

• Colberg, S.R., Sigal, R.J., Fernhall, B., Regensteiner, J.G., Blissmer, B.J., Rubin, R.R., Chasan-Taber, L., Albright, A.L., & Braun, B. (2010). Exercise and Type 2 Diabetes, The American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care, 33, 147-167.

• Considine, R. V., Sinha, M.K., Heiman, M.L et al (1996). Serum immunoreactive-leptin concentrations in normal-weight and obese humans. New England Journal of Medicine, 334, 292-295.

• Diabetes UK (2013). Statistics : diabetes prevalence. Retreived January 13, 2014, from http://www.diabetes.org.uk/About_us/What-we-say/Statistics/Diabetes-prevalence-2012/

• Hu, F. B., Sigal, R.J., Rich-Edwards, J.W., Colditz, G.A., Soloman, G.G., Willett, W.C., Speizer, F.E., & Manson, J.E. (1999). Walking Compared With Vigorous Physical Activity and Risk of Type 2 Diabetes in Women. A Prospective Study. Journal of American Medical Association, 282(15), 1433-1439.

• Hu, G., Lindstro¨m, J., Valle, T.T., Eriksson, J.G., Jousilahti, P., Silventoinen, K., Qiao, Q., & Tuomilehto, J. (2004). Physical Activity, Body Mass Index, and Risk of Type 2 Diabetes in Patients With Normal or Impaired Glucose Regulation. Archives of Internal Medicine, 164,892-896.

• NHS Choices (2013). Latest obesity Stats for England are alarming. Retreived January 13, 2014, from http://www.nhs.uk/news/2013/02February/Pages/Latest-obesity-stats-for-England-are-alarming-reading.aspx

• Umpierre, D., Ribeiro, P.A.B., Kramer, C.K., Leita, C.B., Zucatti, A.T.N., Azevedo, M.J., Gross, J.L., Ribeiro, J.P., & Schaan, B.D. (2011). Physical Activity Advice Only or Structured Exercise Training and Association With HbA1c Levels in Type 2 Diabetes. A Systematic Review and Meta-analysis. Journal of American Medical Association, 305 (17), 1790-1799.

• van Dijk, J.W., Manders, R. J. F., Tummers, K., Bonomi, A. G., Stehouwer, C. D. A., Hartgens, F., & van Loon, L. J. C. (2012). Both resistance- and endurance-type exercise reduce the prevalence of hyperglycaemia in individuals with impaired glucose tolerance and in insulin-treated and non-insulin-treated type 2 diabetic patients. Diabetologia, 55, 1273-1282.

sigalcCOPYRIGHT © PURE TRAINING AND DEVELOPMENT

Thank youfor participating in todays training

Any Questions?

Tutor: Emma Howardt: 03302231302

e: [email protected] w: www.puretraininganddevelopment.co.uk

/PureTrainingandDevelopment @PureTraining2


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