Pre & Postprandial Pre & Postprandial Brief(5 minutes!) Muscle Brief(5 minutes!) Muscle

Training for Management of Training for Management of Blood GlucoseBlood Glucose

Kathleen Broomall, Ph.D.Kathleen Broomall, Ph.D.

Postprandial hyperglycemic Postprandial hyperglycemic spikespike

Glycemic index, postprandial glycemia, and the shape of the curve inhealthy subjects: analysis of a database of more than 1000 foods1,2

Brand-Miller et al_ 89 (1) 97 -- American Journal of Clinical Nutrition

Types of DiabetesTypes of Diabetes Type 1 diabetes, formerly called juvenile diabetes, is usually Type 1 diabetes, formerly called juvenile diabetes, is usually

first diagnosed in children, teenagers, and young adults. In first diagnosed in children, teenagers, and young adults. In this form of diabetes, the pancreas no longer makes insulin this form of diabetes, the pancreas no longer makes insulin because the body’s immune system has attacked and because the body’s immune system has attacked and destroyed the pancreatic cells specialized to make insulin. destroyed the pancreatic cells specialized to make insulin. These insulin-producing cells are called beta cells.These insulin-producing cells are called beta cells.

Type 2 diabetes, formerly called adult-onset diabetes, is the Type 2 diabetes, formerly called adult-onset diabetes, is the most common form. People can develop type 2 diabetes at most common form. People can develop type 2 diabetes at any age, even during childhood. This form of diabetes any age, even during childhood. This form of diabetes usually begins with insulin resistance, a condition in which usually begins with insulin resistance, a condition in which muscle, liver, and fat cells do not use insulin properly. As a muscle, liver, and fat cells do not use insulin properly. As a result, the body needs more insulin to help glucose enter result, the body needs more insulin to help glucose enter cells to be used for energy. At first, the pancreas keeps up cells to be used for energy. At first, the pancreas keeps up with the added demand by producing more insulin. In time, with the added demand by producing more insulin. In time, however, the pancreas loses its ability to secrete enough however, the pancreas loses its ability to secrete enough insulin in response to meals.insulin in response to meals.

Diagnostic Criteria for DiabetesDiagnostic Criteria for Diabetes

Fasting Plasma Glucose Result Fasting Plasma Glucose Result (mg/dL) Diagnosis (mg/dL) Diagnosis

99 or below Normal 99 or below Normal 100 to 125 Pre-diabetes (Impaired Fasting 100 to 125 Pre-diabetes (Impaired Fasting

Glucose) Glucose) 126 or above Diabetes126 or above Diabetes

Diagnostic Criteria for DiabetesDiagnostic Criteria for Diabetes

2-Hour Postprandial Plasma Glucose 2-Hour Postprandial Plasma Glucose Result (mg/dL) Diagnosis Result (mg/dL) Diagnosis

• 139 and below Normal 139 and below Normal • 140 to 199 Pre-diabetes (Impaired 140 to 199 Pre-diabetes (Impaired

Glucose Tolerance) Glucose Tolerance) • 200 and above Diabetes200 and above Diabetes

Pre-DiabetesPre-Diabetes

Pre-diabetes is a condition in which blood Pre-diabetes is a condition in which blood glucose levels are higher than normal but not glucose levels are higher than normal but not high enough for a diagnosis of diabetes. This high enough for a diagnosis of diabetes. This condition is sometimes called impaired fasting condition is sometimes called impaired fasting glucose (IFG) or impaired glucose tolerance glucose (IFG) or impaired glucose tolerance (IGT), depending on the test used to diagnose it. (IGT), depending on the test used to diagnose it. The U.S. Department of Health and Human The U.S. Department of Health and Human Services estimates that about one in four U.S. Services estimates that about one in four U.S. adults aged 20 years or older—or 57 million adults aged 20 years or older—or 57 million people—had pre-diabetes in 2007.people—had pre-diabetes in 2007.

Metabolic SyndromeMetabolic Syndrome Metabolic syndrome is defined as the presence of Metabolic syndrome is defined as the presence of

any three of the following conditions:any three of the following conditions: waist measurement of 40 inches or more for men and waist measurement of 40 inches or more for men and

35 inches or more for women 35 inches or more for women triglyceride levels of 150 milligrams per deciliter triglyceride levels of 150 milligrams per deciliter

(mg/dL) or above, or taking medication for elevated (mg/dL) or above, or taking medication for elevated triglyceride levels triglyceride levels

HDL, or “good,” cholesterol level below 40 mg/dL for HDL, or “good,” cholesterol level below 40 mg/dL for men and below 50 mg/dL for women, or taking men and below 50 mg/dL for women, or taking medication for low HDL levels medication for low HDL levels

blood pressure levels of 130/85 or above, or taking blood pressure levels of 130/85 or above, or taking medication for elevated blood pressure levels medication for elevated blood pressure levels

fasting blood glucose levels of 100 mg/dL or above, or fasting blood glucose levels of 100 mg/dL or above, or taking medication for elevated blood glucose levelstaking medication for elevated blood glucose levels

Role of postprandial spike in Role of postprandial spike in Cardiovascular DiseaseCardiovascular Disease

Review article doi: 10.1111/j.1742-1241.2006.01168.x

Abnormal Glucose Metabolism may be underestimated in

Heart Patients

Conclusions: Abnormal Glucose Metabolism is prevalent (found in >28% of patients tested) and underestimated in Primary Hypertension Coronary Heart Disease patients with normal Fasting Blood Glucose, and it will develop even if therapeutic life-style changes are adopted. Except for FBG, more attention should be paid to postprandial blood glucose. Oral Glucose Tolerance Test should be a routine procedure for PH patients, especially in-hospital PH patients, regardless of normal FBG, and active drug intervention for Impaired Glucose Tolerance patients with PH may

be recommended. “Glucometabolic state of in-hospital primary hypertension

patients with normal fasting blood glucose in a sub-population in China”  Diabetes Metab Res Rev 2009, Mar 6 (epub)

Exercise and Diabetes: Current Exercise and Diabetes: Current RecommendationsRecommendations

Various recommendations Various recommendations 30 minutes exercise 5 days a week30 minutes exercise 5 days a week By Borg scale: 12/13 is a brisk walk for 15-By Borg scale: 12/13 is a brisk walk for 15-

20 minutes 4-7 days a week (breathing 20 minutes 4-7 days a week (breathing through mouth, feeling warm, starting to through mouth, feeling warm, starting to perspire, but able to continue activity)perspire, but able to continue activity)

Thought to improve insulin sensitivity, Thought to improve insulin sensitivity, improves overall glucose homeostasisimproves overall glucose homeostasis

Exercise and Muscle Glut 4 Exercise and Muscle Glut 4 Sugar ReceptorSugar Receptor

GLUT4: a key player regulating glucose GLUT4: a key player regulating glucose homeostasis?homeostasis? ((Molecular Membrane Biology, 2001, 18, 205- Molecular Membrane Biology, 2001, 18, 205- 211)211)

In patients with Type II diabetes mellitus, reduced In patients with Type II diabetes mellitus, reduced glucose transport in skeletal muscle is a major factor glucose transport in skeletal muscle is a major factor responsible for reduced whole body glucose uptake.responsible for reduced whole body glucose uptake.

Thus, GLUT4 is an attractive target for pharmacological Thus, GLUT4 is an attractive target for pharmacological intervention strategies to control glucose homeostasis.intervention strategies to control glucose homeostasis.

There are at There are at least two separate pathwaysleast two separate pathways by which glucose by which glucose transporttransport and GLUT4 translocation can be activated in skeletal and GLUT4 translocation can be activated in skeletal muscle; muscle; one stimulated by insulinone stimulated by insulin or insulin mimicking agents or insulin mimicking agents and and one one activated by activated by muscle contractionsmuscle contractions or or hypoxiahypoxia (Douen (Douen et al. 1990, Cartee et et al. 1990, Cartee et al. 1991, Lund et al. 1995, Zierath et al. al. 1991, Lund et al. 1995, Zierath et al. 1997).1997).

When the two When the two pathways are stimulated concurrently, pathways are stimulated concurrently, glucose transport and GLUT4 translocation are increased glucose transport and GLUT4 translocation are increased in an additive mannerin an additive manner((Wallberg-Henriksson and Hollosz y 1985, Lund Wallberg-Henriksson and Hollosz y 1985, Lund et al. 1995).et al. 1995).

Can exercise minimize Can exercise minimize postprandial damage ?postprandial damage ?

““Can exercise minimize postprandial oxidative Can exercise minimize postprandial oxidative stress in patients with TypeII Diabetes? “stress in patients with TypeII Diabetes? “Curr Diabetes Rev 2008, Nov 4(4) 309-19Curr Diabetes Rev 2008, Nov 4(4) 309-19

Acute and chronic exercise can:Acute and chronic exercise can:1.1. Cause an increase in endogenous antioxidant enzyme Cause an increase in endogenous antioxidant enzyme

activity.activity.2. Improve blood glucose clearance via enhanced 2. Improve blood glucose clearance via enhanced

Glut 4 Glut 4 ((contraction stimulated uptake of sugar into contraction stimulated uptake of sugar into muscles is still effective in Type II diabetics, while insulin muscles is still effective in Type II diabetics, while insulin receptors are ineffective – insulin resistant.)receptors are ineffective – insulin resistant.)

3.3. Improves blood triglyceride and lipoprotein lipase Improves blood triglyceride and lipoprotein lipase activity.activity.

““Can exercise minimize postprandial Can exercise minimize postprandial oxidative stress in patients with Type II oxidative stress in patients with Type II

Diabetes? “Diabetes? “Curr Diabetes Rev 2008, Nov 4(4) 309-19Curr Diabetes Rev 2008, Nov 4(4) 309-19

Muscle Absorption of Sugar Occurs within Minutes of

Contraction “Acute exercise has two separate

effects on skeletal muscle glucose transport. One effect, which is observed during and shortly after exercise, is an insulin-independent stimulation of glucose transport.” “Can “Can exercise minimize postprandial oxidative stress in patients with TypeII exercise minimize postprandial oxidative stress in patients with TypeII Diabetes? “Diabetes? “

Curr Diabetes Rev 2008, Nov 4(4) 309-19Curr Diabetes Rev 2008, Nov 4(4) 309-19

Method of Postprandial Muscle Method of Postprandial Muscle TrainingTraining

Brief muscle activity done within 60 minutes of meal, geared Brief muscle activity done within 60 minutes of meal, geared toward efficient contractile activity with light cardio, with ease of toward efficient contractile activity with light cardio, with ease of accessibility for the average person (5-7 minutes, depending on accessibility for the average person (5-7 minutes, depending on individual needs). The most effective method is to do some work individual needs). The most effective method is to do some work just before the meal, then test blood sugar at 90 minutes, then just before the meal, then test blood sugar at 90 minutes, then do additional work if necessary, according to personal do additional work if necessary, according to personal preference. Some examples are:preference. Some examples are: Climbing stairs, walking between flightsClimbing stairs, walking between flights Walking on slight inclineWalking on slight incline Resistance training, with walking betweenResistance training, with walking between Optimally, would like to randomly sample postprandial blood Optimally, would like to randomly sample postprandial blood

sugar to check effectiveness for individual (return to 100-120)sugar to check effectiveness for individual (return to 100-120)

Control of postprandial spike Control of postprandial spike with 5-10 minutes exercisewith 5-10 minutes exerciseBefore postprandial muscle training, used 20-30 minutes long duration exercise,7 days per week

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Postprandial short interval muscle training suppresses blood sugar spike in reliable and predictable way. (N=1)

Control of Fasting Blood Control of Fasting Blood GlucoseGlucose

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Postprandial short interval muscle training provided better control of fasting blood glucose. (N=1)

Overall Improvement of Overall Improvement of Glucose HomeostasisGlucose Homeostasis

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Postprandial short interval muscle training provided better overall control of glucose homeostasis (exercise on stairs or treadmill, with a sprained ankle!). (N=1)

Improvement in A1CImprovement in A1C A1C reflects average blood sugar A1C reflects average blood sugar

over past 90 daysover past 90 days Normal: 5-6%Normal: 5-6% Diabetic: 7%Diabetic: 7%

Spring 2008: 6.5%Spring 2008: 6.5% Spring 2009: 5.8% (Even with increase in Spring 2009: 5.8% (Even with increase in

BMI)BMI)

Uses/Advantages of Pre & Postprandial Uses/Advantages of Pre & Postprandial Muscle Training: Muscle Training: DISEASE PREVENTION, DISEASE PREVENTION,

and SLOW PROGRESSION!and SLOW PROGRESSION!

Very safe for use in pre-diabetic, decreases their Very safe for use in pre-diabetic, decreases their cardiovascular risk and slows or prevents cardiovascular risk and slows or prevents progression of disease.progression of disease.

Builds optimal amount of muscle, because Builds optimal amount of muscle, because muscle fibers are benefitting from increased muscle fibers are benefitting from increased frequency of glucose absorption. (Type II frequency of glucose absorption. (Type II diabetics’ muscles atrophy faster than normal, diabetics’ muscles atrophy faster than normal, and have abnormal histology.)and have abnormal histology.)

Better muscle health equals greater ease of Better muscle health equals greater ease of compliance.compliance.

May help prevent weight regain because sugar May help prevent weight regain because sugar actively absorbed into muscles, not into adipose actively absorbed into muscles, not into adipose tissues.tissues.

Advantages of Pre & Postprandial Muscle Training

Pre & Postprandial muscle training is what Pre & Postprandial muscle training is what nature intendednature intended – – our glucose homeostasis was our glucose homeostasis was never intended to rely solely on our insulin receptor never intended to rely solely on our insulin receptor system. Instead, we are meant to use our muscles as a system. Instead, we are meant to use our muscles as a secondary regulatory system, in conjunction with our secondary regulatory system, in conjunction with our insulin receptor system. Apparently, this secondary insulin receptor system. Apparently, this secondary system in our muscles operates with amazing efficiency, system in our muscles operates with amazing efficiency, such that we can easily and quickly activate this muscle such that we can easily and quickly activate this muscle based (insulin independent) blood sugar regulatory based (insulin independent) blood sugar regulatory system with a few simple muscle contraction events, then system with a few simple muscle contraction events, then continue with our busy, however sedentary, lifestyles.continue with our busy, however sedentary, lifestyles.

““Resistance exercise increases postprandial muscle Resistance exercise increases postprandial muscle protein synthesis in humans”, Med Sci Sports Exerc 2009 protein synthesis in humans”, Med Sci Sports Exerc 2009 Jan; 41 (1): 144-54.Jan; 41 (1): 144-54. Postprandial exercise may be a very efficient way to build new Postprandial exercise may be a very efficient way to build new

muscle fiber, which helps regulate blood sugar even at rest.muscle fiber, which helps regulate blood sugar even at rest.

Interested PartiesInterested Parties IndividualsIndividuals Companies wanting to cut health care costs can Companies wanting to cut health care costs can

incentivize behaviorincentivize behavior Parents and schoolsParents and schools Exercise equipment sellersExercise equipment sellers Blood glucose meter producers, especially bloodless Blood glucose meter producers, especially bloodless

“real time” meters in development“real time” meters in development GOVERNMENT – GOVERNMENT – for DISEASE PREVENTION AND for DISEASE PREVENTION AND

LOWERING OF HEALTH CARE COSTSLOWERING OF HEALTH CARE COSTS Individuals without good access to health care and Individuals without good access to health care and

therefore poor management of blood sugartherefore poor management of blood sugar