New Paper: How to Get Patients With Diabetes/CVD Moving

Marlene Busko

January 22, 2019

A new position paper from the European Association of Preventive Cardiology (EAPC) recommends, among other things, that physicians "prescribe" exercise and/or activity to patients with both type 2 diabetes and cardiovascular disease to reduce premature death.

"Diabetes doubles the risk of mortality but the fitter patients become, the more that risk declines. Unfortunately, the majority of patients do not engage in exercise programs," notes lead author Hareld M.C. Kemps, MD, PhD, Department of Cardiology, Maxima Medical Center, Veldhoven, The Netherlands, in a statement issued by the European Society of Cardiology on January 14, which coincided with publication of the paper online in the European Journal of Preventive Cardiology.

The position paper, entitled "Exercise training for patients with type 2 diabetes and cardiovascular disease: What to pursue and how to do it," provides practical recommendations for physicians on how to motivate patients to incorporate physical activity into their daily routine, set achievable and measurable goals, and design individualized exercise training programs to meet those goals.

"Just advising patients to exercise, which is what doctors typically do, is not enough,” he said. "They must be assessed for comorbidities, risks related to exercise, and personal preferences. This will be cost effective in the long run."

Kemps told Medscape Medical News that the key takeaway messages of the position paper are:

  • Exercise training should be a very important part of the treatment of all type 2 diabetes patients with coexisting cardiovascular disease.

  • Patients should aim to increase physical fitness and glucose regulation [rather than focus on weight loss].

  • Exercise programs should be personalized based on an individual's barriers to exercise and risk assessment, and to increase long-term progress should be monitored.

Evidence Supports Aerobic Exercise, Regular Feedback Essential

Most patients with type 2 diabetes seen in clinical practice, including those with coronary artery disease, do not participate in regular physical activity, the authors write.

However, patients who do exercise regularly can benefit from improved glucose control, blood pressure, lipid status, or body composition. For example, aerobic exercise can increase cardiorespiratory fitness (VO2 max measured on a treadmill or stationary bicycle) and improve glycemic control.

Most guidelines recommend aerobic exercise training for patients with diabetes based on large studies.

"Traditional exercise programs for cardiovascular rehabilitation have mainly employed continuous [aerobic exercise training], such as walking, running, cycling, or swimming," the authors note, which use large muscle groups and increase heart rate, and the duration of these protocols can be increased gradually.

However, resistance training has also been included in rehabilitation exercise programs and shown to be safe in patients with type 2 diabetes.

Meta-analyses have suggested that three to five training sessions per week are optimal to decrease HbA1c enough to reduce the risk of diabetes-related complications, but the ideal duration, volume, and intensity of aerobic exercise training depends on the individual patient.  

And a goal of increased physical fitness might be better than weight loss to motivate patients, the authors stress.

In addition, exercise training can support but not replace lipid-lowering medication for achieving target values indicated by current guidelines.  

Most patients show at least some positive effects on surrogate markers of cardiovascular health, say Kemps and colleagues.

But they stress that "regular motivational feedback, for example, by telemonitoring, is crucial to adherence and needs to be maintained."

For example, in the LookAHEAD study, a gradual loss of benefit after the first year coincided with a gradual decline in counseling frequency. And in another large study, patients with diabetes, especially women, were less likely to complete a 1-year cardiac rehabilitation program.

Remote guidance is also useful, say the authors, with patients monitoring themselves with smartwatches then sending data to a health professional for feedback.

Simply Walking and Reducing Sedentary Time Still of Benefit

The authors also stress that simply reducing sedentary time by interrupted sitting is a promising intervention for improving glycemic control.

"Patients at risk or severely detrained patients should start exercising at low intensity, with each increment to be supervised closely, aiming at integration of regular physical activity into daily routine."

However, he noted that "there are also steps patients can take without needing to see a doctor first, such as interrupting sitting time and doing moderate exercise like walking and cycling."

"I can't stress enough how effective even small increases in activity can benefit patients with type 2 diabetes and heart problems," he said.

"Interrupting sitting with brief bouts of walking improves glucose control, while 2 hours of brisk walking per week reduces the risk of further heart problems."

The authors did not receive funding for this study and did not report any relevant financial relationships.

Eur J Prev Cardiol. Published online January 14, 2019. Article

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