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Is Physical Exercise a Core Therapeutical VO2max (2,10,16), mitochondrial bio-genesis (16), and insulin sensitivity(5,17,18). In subjects with type 2 diabe-tes, regular aerobic, resistance, or com- Overthelastdecade,growingscien- compliancewithanexerciseregimenre- bined exercise training results in a both in the diabetes team operators/facil- peutic strategy for type 2 diabetes (1–12).
itators and in their patients, and is based on a strong therapeutic alliance. There are several obstacles in this virtuous process: lack of time and lack of confidence in the tion, exercise therapy should be part of a at a speed of 4–5 km/h. However, benefi- structured lifestyle intervention and in- ators, unhealthy lifestyles of physicians cial effects can be obtained with a lesser clude both aerobic and resistance training effort, and for this reason the statements of scientific societies recommend at least change their lifestyle, mainly due to poor self-efficacy or lack of time (15). The “no” side of this debate will discuss the evi- three weekly sessions of resistance exer- ture beyond resting expenditure. Exercise dence in the literature on the strategies cise to increase muscle strength (13,14).
The intensity of exercise should be in the planned, structured, repetitive, and pur- clinical applicability of guidelines. In the “yes” side, we report the evidence that ex- 2 diabetic subjects are not familiar with ercise works in the research setting and in the “no” side, that often exercise therapy fails in the primary care setting and what intensity exercise can be sustained for a moderate-intensity/long distances increa- ses insulin sensitivity up to 14 days after the end of the last exercise session (18) ever, training modalities for type 2 dia- demonstrated numerous beneficial effects effects, precautions, and limitations of the for health and society, support the use of and necessitate further investigation.
use of exercise in type 2 diabetic subjects.
exercise as a core element in treatment of Another crucial point that merits discus- people with type 2 diabetes (1–14).
exercise therapy suggested by scientific ted beneficial effects of exercise in type 2 guidelines and the applicability of it in low and high intensity, in a small number of subjects with type 2 diabetes (20). Con-tinuous walking in comparison with the c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c From 1Healthy Lifestyle Institute CURIAMO, University of Perugia, Perugia, Italy; and the 2Department of Medicine III, Prevention and Care of Diabetes, University of Dresden, Dresden, Germany.
This publication is based on the presentations from the 4th World Congress on Controversies to Consensus in Diabetes, Obesity and Hypertension (CODHy). The Congress and the publication of this supplement weremade possible in part by unrestricted educational grants from Abbott, AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Eli Lilly, Ethicon Endo-Surgery, Janssen, Medtronic, Novo Nordisk, Sanofi, and mended to maintain the beneficial effects 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for pro physical activity are often referred to as DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 after significant weight loss (22,23). Inter- A post hoc subgroup cost analysis has es- timated that the ideal financial savings are study demonstrate that the beneficial ef- fects of the lifestyle intervention are inde- pendent of the degree of baseline obesity 27 MET z h/week (3). It is critical to pro- duce studies comparing the cost/utility of intensive lifestyle group had similar ad- status of type 2 diabetic subjects (29,30).
multidisciplinary lifestyle interventions These two beneficial effects support the lifestyle interventions in obesity and type 2 diabetes have the potential to counter- positive outcomes not entirely achievable type 2 diabetes at the end of a multidisci- plinary lifestyle intervention, in which ex- strate also that in overweight adults, an individuals to change their lifestyle and to intensive lifestyle intervention is associ- introduce exercise into a daily routine. In ated with a greater likelihood of partial this regard, we need more studies report- tinctive result not achievable with phar- ing patients’ views on barriers and fa- identifying the psychological profile of have limitations in mobility that increase (12,23). The current literature indicates of modifiable cardiovascular risk factors sive lifestyle intervention that produces that participants in lifestyle intervention tory fitness (2,8,10,16). Several prospec- slow the loss of mobility in such patients tive studies have demonstrated a significant the staff (32,40), that motivation is in- inverse relationship between cardiorespi- ratory fitness and all-cause risk of death in strategy to treat type 2 diabetes because sicians, nurses, dietitians, exercise phys- the counseling strategy to advise exercise entails empathy and listening (15,34). Di- take) reduces the risk of death by ~18% in rective models of diabetes care often re- of health-related quality of life predict core element of a multidisciplinary life- (41), whereas greater self-reported phys- style intervention, considers patients as ical activity (23) or attendance at exer- tional Institutes of Health because the in- correlate of weight loss. The “no” side of this debate will further discuss these aspects on the use of exercise in the clin- which was the primary study goal (28).
chronic illnesses such as diabetes (37).
At the time, participants had been in the intervention for up to 11 years and the in- tensive lifestyle intervention has been able to achieve and maintain weight loss by de- There is no doubt that physical activity is creased caloric intake and increased phys- change the patient’s perception of exer- ical activity (28). Thus, at present there is cise from a sacrifice to a pleasant experi- have very good scientific evidence that an no conclusive evidence that regular exer- cise can significantly reduce cardiovas- 2 diabetes, more research is necessary to tients (1–14,24), as it is also an important analyze the cost-effectiveness of exercise strategy for diabetes prevention (38,42).
On the other hand, there is no doubt that to deliver such interventions. At present, there is promising evidence that exercise practice not always leads to the expected cular disease risk prior to starting exer- cise is important to minimize the risk of physical activity strategies in praxis reach and treating type 2 diabetes (3,39).
DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 active and there is no added value for the based brisk walking represents an equally physically inactive (42). Resistance train- applicable to daily life and our environ- effective intervention to modulate glyce- ing is confronted with a particularly high load of barriers, since the patient needs to lifestyle. Why isn’t exercise therapy a file in type 2 diabetic patients compared with more individualized medical fitness attend a gym, and have a training plan.
strategy, setting new goals for the “daily that “sports” in diabetes therapy fails to a “walk.” We are not “exercise” machines, step count” has a much higher chance of large extent and that we need “improved” strategies to successfully increase physical the “no” side have been presented in the burn less energy, gain visceral adiposity, tion and capability, both in the diabetic lyzing barriers to behavior change (52).
patients, and is based on a strong thera- to provide “behavioral support” and en- peutic alliance.” There are additional in- for all of our patients with diabetes and treat them with specific exercise programs extrapolate that walking 10,000 steps/day sion for our patients, which is unrealistic many chronic diseases. Yates and coworkers achieving the required changes reliably is lifestyle intervention, considers patients as active participants in their own treat- predictor of reliably increased effective- patients have failed. The physical activity treatment,” and this is only achievable diabetic patients in the primary care set- ting and only reaches a very tiny fraction home. Behavior change affects our private style change in people with type 2 diabe- of diabetic patients because it focuses too tes including those with disease risk.
much on “exercise therapy” and lacks an adequate behavioral strategy as a pillar/ physical activity in our patients, we can walking steps is something that we do ev- only succeed with behavioral intervention ery day and in all situations of our life; it is that has been adequately initiated. Exercise already part of our daily lifestyle. Behav- therapy has failed in the past because it has ioral support can help us analyze the mo- tivation to change lifestyle and to set new lifestyle intervention to treat and prevent goals for lifestyle change. Action plans, as type 2 diabetes, especially when incorpo- part of a behavioral strategy, can help pa- rated into a multidisciplinary lifestyle in- tients reach goals and find ways to stim- tervention. The evidence has been firmly ulate success and reduce relapse (50). For established by several clinical trials. The modification of physical activity behav- plementation of the evidence into clinical on the strategies that already exist in daily life than to focus on “therapeutic” strate- question about the key items for changing low (1). Therefore, behavioral intervention DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 benefits from multidisciplinary lifestyle 6. Sigal RJ, Kenny GP, Boulé NG, et al. Ef- sue. Physical activity is a good sign of be- fects of aerobic training, resistance train- ing, or both on glycemic control in type 2 tional sessions (41). The multidisciplin- 7. Yates T, Khunti K, Bull F, Gorely T, Davies strategy, the more success it will have in management of impaired glucose tolerance: a systematic review. Diabetologia 2007;50: the masses with the right behavioral sup- Jeffriess L, Prins JB, Marwick TH. Effects therapy is a therapy associated with a dis- operators of the multidisciplinary diabe- this is only applicable for a fraction of and provide an example to their patients.
9. Church TS, Blair SN, Cocreham S, et al.
Effects of aerobic and resistance training our patients. For it to be true that “phys- 2 diabetes,” we have to improve our un- are more likely to provide lifestyle advice 10. Balducci S, Zanuso S, Nicolucci A, et al.; ological as well as contextual mechanisms of his letters to Lucilio, “People believe Investigators. Effect of an intensive exer- disease itself. To reach every patient, we cise intervention strategy on modifiable cardiovascular risk factors in subjects with natural than walking, and to walk our di- controlled trial: the Italian Diabetes andExercise Study (IDES). Arch Intern Med abetes away is effectively achievable. Pa- AcknowledgmentsdNo potential conflicts of interest relevant to this article were reported.
11. Umpierre D, Ribeiro PA, Kramer CK, et al.
P.D.F. wrote DISCUSSION OF THE “YES” SIDE OF Physical activity advice only or structured gain even more individual benefit. Future THE DEBATE. P.S. wrote DISCUSSION OF THE “NO” directions for research in this field should SIDE OF THE DEBATE. P.D.F. is the guarantor of this work and, as such, had full access to all the data and takes responsibility for the in- creased physical activity into daily activity tegrity of the data and the accuracy of the data 12. Unick JL, Beavers D, Jakicic JM, et al.; versus specific prescription of aerobic and tiveness of lifestyle interventions forindividuals with severe obesity and type be on lifestyle change rather than a pre- scription for exercise per se. Thus, exer- GA, Sigal RJ. Effects of exercise on gly- cise support should be part of a structured 13. Marwick TH, Hordern MD, Miller T, et al.; addresses the mechanistic basis of type 2 diabetes. Physical activity is therefore a GA, Sigal RJ. Meta-analysis of the effect ing; Council on Nutrition, Physical Ac-tivity, and Metabolism; Interdisciplinary diorespiratory fitness in Type 2 diabetesmellitus. Diabetologia 2003;46:1071– Research. Exercise training for type 2 di- 3. Di Loreto C, Fanelli C, Lucidi P, et al.
abetes mellitus: impact on cardiovascular risk: a scientific statement from the Ameri- can physical activity express its maximum physical activity on type 2 diabetes. Di- for every patient with type 2 diabetes.
14. Colberg SR, Albright AL, Blissmer BJ, behavioral support is treated as a justifi- glucose control and risk factors for com- sition statement. Exercise and type 2 di- tion of diabetes educators, exercise phys- 5. Thomas DE, Elliott EJ, Naughton GA.
Exercise for type 2 diabetes mellitus.
15. Kirk A, De Feo P. Strategies to enhance compliance to physical activity for patients DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 with insulin resistance. Appl Physiol Nutr 41. Mazzeschi C, Pazzagli C, Buratta L, et al.
16. Fatone C, Guescini M, Balducci S, et al.
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34. Di Loreto C, Fanelli C, Lucidi P, et al.
strategies for weight loss and prevention 47. Yates T, Davies MJ, Sehmi S, Gorely T, of weight regain for adults. Med Sci Sports Khunti K. The Pre-diabetes Risk Education dividuals successful at long-term mainte- nance of substantial weight loss. Am J Clin problem with compliance in diabetes.
23. Wadden TA, West DS, Neiberg RH, et al.; 36. De Feo P, Fatone C, Burani P, et al. An styles of persons with obesity and/or Type 24. Gregg E, Chen H, Wagenknecht LE, et al.; ment and self-management of diabetes.
49. Schwarz PE, Greaves CJ, Lindström J, tion of an intensive lifestyle intervention interventions for the prevention of type 2 25. Myers J, Prakash M, Froelicher V, Do D, 39. Roine E, Roine RP, Räsänen P, Vuori I, nents associated with increased effective- 26. Kokkinos P, Myers J, Nylen E, et al. Ex- ercise capacity and all-cause mortality in cise in the treatment of various diseases: with type 2 diabetes. Diabetes Care 2009; 51. Praet SF, van Rooij ES, Wijtvliet A, et al.
27. Sluik D, Buijsse B, Muckelbauer R, et al.
40. Casey D, De Civita M, Dasgupta K. Un- for patients with type 2 diabetes: a rando- derstanding physical activity facilitators mised controlled trial. Diabetologia 2008; 28. Weight loss does not lower heart dis- diabetes: a qualitative study. Diabet Med training in Type 2 diabetes: a randomized, DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013 54. Foster C, Hillsdon M, Thorogood M. Inter- 56. Schwarz PE, Albright AL. Prevention of ventions for promoting physical activity. Co- type 2 diabetes: the strategic approach for 53. Avenell A, Broom J, Brown TJ, et al. Sys- tematic review of the long-term effects and 55. Tuomilehto J, Schwarz P, Lindström J.
Long-term benefits from lifestyle inter- time to expand the efforts. Diabetes Care obesity care and beliefs. Obesity (Silver DIABETES CARE, VOLUME 36, SUPPLEMENT 2, AUGUST 2013

Source: http://www.diabetesliteracy.eu/system/files/documents/2013_DeFeo_Exercise.pdf


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