Book_WCPD 2008.Simovska Vera.MD.,PhD. Helsinki.

8/14/2019 Book_WCPD 2008.Simovska Vera.MD.,PhD. Helsinki.

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5th

WORLD CONGRESS OF PREVENTION OF DIABETES AND ITS COMPLICATIONS

June, 1-4, 2008, Helsinki, Finland

Title:

A proposal - a measure in the modern concept of type-2 diabetes (T2DM) prevention focused on

increasing cardiorespiratory fitness and macronutrient content of diet at high-risk obese adult and

elderly population

Author:Simovska Vera., MD., PhD.

Institution:HEPA Macedonia National organization for the promotion of health-enhancing physical activity, Skopje,

Macedonia, FYR

Introduction/Aims:Obesity is known to lead to many health issues: metabolic complications that increase the risk for

development of type-2 diabetes (T2DM) in adult and elderly population (elderly diabetes),

cardiovascular diseases, and joint public health problems.

Our objectives were to promote preventive-therapeutic programmes with a proposal - a measure forincreasing cardiorespiratory fitness (VO2max) and macronutrient content of diets intended for obese adult

and elderly population with abdominal fat distribution who are asymptomatic, but at high-risk for

development of T2DM.

Method:Within the 7 week clinically controlled trial at a group of 82 middle-aged subjects (24-65 years) devided

into two intervention groups: physical activity and diet (PAD) and diet (D) with mean BMI = 32.6 kg/m2

and present

pre-diabetes (a fasting plasma glucose of 100 140 mg/dl after an overnight fast), the following wereapplied: individually dosed, programmed physical activity (PA) and moderate energy reduced

diet,performed into two phases.

A proposal - a measure for increasing VO2max with aim to reduce T2DM risk included: 30 minutes daily

in 3 bouts of ten minutes or 2 bouts of 15 minutes of moderate-intensity physical activity (3.0 - 4.5 METs

for male; 2.1 - 4.2 METs for female) with training pulse of 50 - 59% heart rate maximum reserve in the

first phase or 45 - 60 minutes, 3 times a week of moderate to vigorous intensity physical activity (4.5 - 7.0

METs for male; 4.2 - 6.3 METs for female) with training pulse of 60% heart rate maximum reserve in

the second phase. Muscle strength and flexibility exercise was included twice a week.In the first phase of the research, moderate energy reduced diet had a character of "a temporary" diet of

1200kcal/d with a specific macronutrient content: CHO=50.1% (Poly CH=47.2%), P=25.7% and

F=25.8% of total energy intake,

a specific relation among SFA, MUFA, PUFA, a low atherogenic potential (AI < 15) and vitamin-mineral

supplementation. The second phase was the increased energetic value of the diet for 200 kcal/d with nextcontent: CHO=54.1% (Poly CH=58.9%), P=26% and F=21.1% of total energy intake.


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Conclusion:

T2DM can be prevented in high-risk truncal obese adult and elderly population using increasing VO 2maxand specific macronutrient content of diets in accordance with our a proposal - a measure.

References:

1. Simovska V: EFFECTS OF DIETOTHERAPY AND PROGRAMMED PHYSICAL ACTIVITY ON

ATHEROGENIC RISK FACTORS IN OBESE SUBJECTS. Ed. Monography. Skopje: Menora 2008,

Macedonia.

2. Simovska V.,Vidin M.: PRESCRIPTION AND MODELLING OF PROGRAMMED PHYSICAL

ACTIVITY IN AN INTEGRATED CVD RISK MANAGEMENT. The International XVIII Puijo

Symposium 2005: Physical Activity in Conuction with Pharmacological Therapy for Chronic Vascular

Diseases, Koupio, Finland 2005. Finnish Sports and Exercise Medicine e-Magazine. The International

XVIII Puijo Symposium special issue 2005.

3. Simovska V: THE PRESENCE OF RISK FACTORS FOR CARDIOVASCULAR DISORDERS IN

THE FAMILY AND EARLY DETECTION IN THEIR CHILDREN. Post-graduate subspecializationthesis, Medical Faculty University of Belgrade, SR Yugoslavia 1993.

4. Simovska V., Pecelj-Gec M., Marinkovic J., Kocev N., Vidin M.: PREDICTION OF EFFECTS OF

NON-PHARMACOLOGICAL TREATMENT AT ABDOMINAL OBESE INDIVIDUALS USING

MATHEMATICAL MODEL. Ist

Yugoslavian Congress for Atherosclerosis with International

Participation, Belgrade 2001. The Book of Abstracts 2001:42.


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Vera Simovska. MD., PhD.

www.cindi.makedonija.com

The question of an integrated T2DM and CVD risk

management at high risk obese subjects is important scientific

problem and every new result opens new questions. It,s

becoming increasingly clear that physical activity may be a

therapeutical tool in a variety of subjects with, or at risk for

T2DM and CVD.

At present, clinical researches of different branch of medicine,

exercise scientists, pharmacists, nutritionists, psychiatrists,

sociologists and many others are surprised with the fact thatfinally healing is achieved at every seventh of hundred obese

individuals with average/ increased and high risk for T2DM,

CVD and other NCD.

Overall scientific results including our data are additional

argument that any other preventive-therapeutic treatment isnot possible to be applied as alteration for physical activity in

an integrated T2DM and CVD risk management.


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INTRODUCTION

Numerous epidemiological, genetically and molecular

studies at different population worldwide confirmed that obesity isassociated with metabolic complications that increase the risk forT2DM, CVD and other NCD. The complex of multifactor phenotype isdetermined of interaction between:

Behavior factors: energy intake and expenditure defined

as affects on body fat mass

Genetics variations (hereditary predisposition)

Different biological factors: sex, vulnerable ages related

to increased weight, ethnically and hormone activity

Community situation

Environmental factors


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OBJECTIVES:

1. To promote preventive-therapeutic programmes with a

proposal-a measure for macronutrient content of diets and

increasing cardiorespiratory fitness (VO2max) intended fortruncal obese subjects who are asymptomatic, but at high-risk for T2DM and CVD.

2. To develop a method for prescription of programmed physical

activity (PA) in accordance with individual performing theexercise and biological characteristics of subjects.

3. To estimate the efficiency of the method on T2DM and CVDrisk reduction at abdominal obese subjects included in 7wkrandomized controlled trial.

4. To construct a new index as mathematical model for predictingthe effects of non-pharmacological therapies at obesepopulation on average/increased and high risk for CVD andother NCD.


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5

MATERIAL AND METHOD:

Within the clinically controlled trial was examined 45 middle-aged

subjects devided into two intervention groups: PAD (physical activity

and diet) and group D (diet) with mean BMI=32.6kg/m2 and present

pre-diabetes (a fasting plasma glucose of 100-140mg/dl after an

overnight fast).

In group PAD the following were applied: moderate energy reduced

diet and individually dosed, programmed physical activity (PA)

performed into two phases.

In the first phase of the research, a diet had a character of

"a temporary" diet of 1200kcal/d with a specific macronutrient content:

CH=50.1% (Poly CH = 47.2 %), P=25.7% and F=25.8% of total EI, a

specific relation among SFA, MUFA, PUFA, a low atherogenic potential

(AI


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6

41

17

5,7

14,5

1

21,4

43

16

9

13,67

0

18,26

30

22,54

6,84

23,14

0

17,37

0

5

10

15

20

25

30

35

40

45

bread

,pasta

meat,

fish

,eggs

fat,

oil

milk

,dairy

products

sugar

,cakes

vegetables

,fruits

1200kcal-Ist phase

1400kcal-IIth phase1300kcal-WHO CIN

1200kcal-Ist phase 1400kcal-IIth phase 1300kcal-WHO CINDI

%

BASIC FOOD GROUPS IN DAILY MAILS

- Ist AND IIth PHASE OF DIETO THERAPY


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Table 3. MACRONUTRIENT CONTENTTable 3. MACRONUTRIENT CONTENTTable 3. MACRONUTRIENT CONTENTTable 3. MACRONUTRIENT CONTENT

CINDI FOOD PYRAMID (WHO,,,, 1998)

Tab-1. An integrated T2DM and CVD risk management included both

PA and hypocaloric diets of 1200 kcal/d as temporary diet and

1400 kcal/d (second phase) with low atherogenic index (AI).


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Tab-2. MICRONUTRIENT CONTENT OF DIETOTHERAPY


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9

GRAF 1. FAT CONTENT (SFA, MUFA, PUFA) IN Ist AND IIst PHASE OF

DIET THERAPY, EXPRESED IN PERCENTAGE OF TOTAL ENERGY INTAKE/24h

9,26

8,84

7,27

5,39

9,49

5,75

10

12

8

0

5

10

15

20

25

30

35%

1 PHASE 2 PHASE AHA/EAS >2000kcal/d

F A T SFA MUFA PUFA

25.43%

20.83%

30%


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10

24.97

75.03

43.71

56.29

60

40

0

10

20

30

40

50

60

70

80

90

100%

1 etapa AHA/EAS>2000kkal/d

PROTEINI

rastit.proteini `ivot.proteini

25.28% 25.73% 16%

52.78

47.22

41.13

58.87

30

70

0

10

20

30

40

50

60

70

80

90

100

%

1 etapa 2 etapa AHA/EAS

>2000kkal/d

merewa

JAGLENI HIDRATI

mono-disaharidi polisaharidi

49.27% 53.43% 60%

GRAF. 2 MACRONUTRIENT CONTENT IN Ist AND IIst PHASE OF DIET THERAPY,EXPRESED IN PERCENTAGE OF TOTAL ENERGY INTAKE (kcal/24h)AND AHA/EAS RECOMMENDATION


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11

- First phase: moderate-intensity PA with TP = 50 % HRMax

reserve, 30 min daily in 2 bouts of 15 min. and

- Second phase: moderate to vigorous-intensity PA with

TP > 60 % HRMax reserve, 60 min per day, 3 times a week.

Using tables for gross energy expenditure of various PA

with known energy cost (METs) were chosen different type

of PA in accordance with initial level of VO2max (METs).

(Poster for Physical Activity and Health).

Muscle strength and flexibility exercise were includedtwice a week.

A proposal - a measure for increasingcardiorespiratory fitness - VO2 max


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METHODS FOR PRESCRIPTION OF PHYSICAL ACTIVITY

1. The basic criterion for patient selection in four groups ofphysical activity levels (PALs) was initial level of VO2maxexpressed in term of metabolic equivalents (METs).

2. MET was calculated by the equation:

VO2max (ml-1kg-1min-1)/3.5

3. The method for modeling of programmed PA

was established using the classification for VO2max(WHO, 1974).

4. Training pulse (% HR max reserve) was calculated using

equation by Karvonen Martin (Tab. 1).

5. Classification for intensity of PA i.e. physical work wasexpressed as energy expenditure in term of METs (Tab. 2).

6. Using tables for gross energy expenditure of various PA withknown energy cost (METs) were chosen different type of PA inaccordance with initial level of VO

2max (METs) (Poster for

Physical Activity and Health).


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Table 3. METHOD FOR PRESCRIPTION AND MODELLING OF

PROGRAMMED PHYSICAL ACTIVITY

Method for prescription and modeling of programmed physical activity

>7.0 m.; >6.3 f.>12 m.; >10 f.75-84%; 85%Training for sport

4.5 - 7.0 m.4.2 - 6.3 f.

8.5-12.0 m.6.8-10 f.

60-74%PAL IIExercise for

fitness

3.0-4.5 m.

2.1-4.2 f.

5.6-8.5 m

4.3-6.8 f50-59%

PAL I

Activity for health


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Tab-4. CLASSlFICATION FOR INTENSITY OF

PHYSICAL ACTIVITY/WORK EXPRESEDAS ENERGY EXPENDITURE (METs)

METs-male

(ANDERSEN)

METs-female

(WHO)

INTENSITY OF

PHYSICAL ACTIVITY/WORK (METs)

< 3.0 < 2.1 LIGHT TO MODERATEACTIVITY

3.0 4.5 2.1 4.2 MODERATE

4.5 7.0 4.2 6.3 MODERATE TOVIGOROUS

> 7.0 > 6.3 STRENUOUSACTIVITY


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Training for sportStrenuous activity

Duration and frequency according to

individual fitness level.

Intensity of work:male >7.0 mets;

female>6.3mets

Relative intensity:HRmax 80-89%; >90 %

HRmax reserve 75-84% ; >85%

Exercise for fitness and increasing performancemoderate to vigorous activity,

20 minutes or more, 3 times a week.

Intensity of work:male 4.5 7.0 mets; female 4.2 - 6.3 mets

Relative intensity: HRmax 68 79% ;

HRmax reserve 60 - 74 %

Activity for healthmoderate activity, 30 minutes or more, daily.

Intensity of work: male 3.0-4.5 mets; female 2.1-4.2 mets

Relative intensity:HRmax 60 67 %;

HRmax reserve 50 59%

Active living

Light to moderate activity, 10 minutes or morea few times a day, daily.

Intensity of work: male < 3.0 mets ; female < 2.1 mets

Relative intensity: HRmax > 35% ; 35 59 %;

HRmax reserve > 30% ; 30 49 %

HR max reserve (training puls) =0.5 (220-years-morning heart rate)+ morning heart rate


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R E S U L T S:

The efficiency of prescribed PA and/or diet therapy on T2DM

and CVD risk reduction was examined in abdominal obesepatients included in 7 week randomized controlled trial.

Improved VO2max at 17.16% from baseline promotedsignificant greater reduction on level of CVD risk factors in FADthan those in D group of obese patients included:

body weight (BWkg.)

% body fat mass (%F)

waist circumference (WC)

waist/hip ratio (WHR)

systolic blood pressure (TA-sist.)

index of atherosclerosis (LDL-C/HDL-C)

Serum glucose (GLY)

HDL was increased at 10.41% from baseline in FAD anddecreased at 9.3% in D group.


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Graf. 3 SUBJECTS DISTRIBUTION IN PHYSICAL ACTIVITY GROUPS(PALs) - INICIAL AND FINAL RESULTS IN FAD GROUP

40

20

50

55

10

0 0

25

0

10

20

30

40

50

60

%

PAL I-ACTIVITY FOR

HEALTH

PAL II-EXERCSE FOR

FITNESS

SPECIAL PROGRAM TRAINING FOR SPORT

GROUP - "FAD"

INICIAL PHASE

FINAL PHASE


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18

00

-176,54

-112,43

-200

-180

-160

-140

-120-100

-80

-60

-40

-20

0

0

BW gr/d

p


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19

5,29

6,17

4,32

4,795,19

4,32

0

1

2

3

4

5

6

7

8

GLy-mmol/l

INICIJAL FINALmerewa

GRUPA FAD GRUPA D GRUPA K

p>0.05p>0.05

MANOVA

4,795,195,29

6,17

0

1

2

3

4

5

6

7

INICIJALNA FINALNA

merewa

GRUPA FAD GRUPA D

p00.05

Graf 5. DESCRIPTIVE CHARACTERISTICS ON GLYCAEMIA (Glymmol/l)

IN INICIAL AND FINAL PHASE AND DINAMICS OF CHANGES


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20

5.60

7.10

3.78

4.76

5.72

3.78

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%%HbA1c

INICIJAL FINALmerewa

GRUPA FAD GRUPA D GRUPA K

p>0.05

p>0.05

MANOVA

4.76

5.60 5.72

7.10

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%

INICIJALNO FINALNO

merewa

%HbA1c

GRUPA FAD GRUPA D

p00.05Graf 6. DESCRIPTIVE CHARACTERISTICS ON %HbA1c IN

INICIAL AND FINAL PHASE AND DINAMICS OF CHANGES


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21

3

3,38

2,17 2,15

3,12

2,17

0

0,5

1

1,5

2

2,5

3

3,5

4

LDLL

-C/HDL-C

INICIAL FINAL

FAD roup D roup K roup

p0.05

MANOVA

2.15

3.123

3.38

0

0.5

1

1.5

2

2.5

3

3.5

4

INICIJALNO FINALNOmerewa

LDL-C/HDL-

c

GRUPA FAD GRUPA D

p0


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22

-3,1

-5,2

0

-10,2

0

14,8

0

17,1

0

5,5

-9,3

10,4

-10,2

-27,7

-7,7

-28,6

-5,6

-9,5

-3,3-4,5

-1,8-3,3

-6,3

-10,3

-5,3

-7,9

-3,5-4,9

-35

-30

-25

-20

-15

-10

-5

0

5

10

15

20

25 %

FAD D

Graf. 8 - Significant changes in level of VO2max and major risk

factors for T2DM and CVD between FAD (physical activity and diet) andD (diet) groups of abdominal obese subjects

TT-I f TT %M LBM WHR OS LDL/HDL TC/HDL

HDL

%Fc-m

VO2max

VO2maxOPV

%FAIBMR


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23

LOGISTIC REGRESSION

Logistic regression was implement with aim to predict those regressors which withtheir values as final result are giving a probability for selecting for either the groupPAD or the group D.

In the analysis are included 50 independent variables, and as outcome variable wasthe group which signified the type of therapeutically treatment among our patients.

The first model of logistic regression shown in a form of equation gives dividingthe patients in one of the groups depending on the value of the exponent (Exp. B)which is interpreted in term of relative risk (RR).

As a result is the prediction of 94.87%.

The result shows that the regressors are separated like the following 6 variables:body mass index-BMIkg/m2, cardio respiratory capacity VO2maxOPV (ml

-1kg-1min-1) as expected average value, indicial level of hemoglobin-Hbin, skin fold thickness

upon m.biceps (SFT-Bin), level of VO2max using by WHO classification and energyexpenditure (kcal/h) during PA with intensity of 50% HRmax reserve (VO2max).Logistic model in form of equation is:

lnRR = 108.2588 1.7689 x DKN-B in + 1.7087 x BMI in+ 0.3993 x Hb in

- 2.9423 x VO2max (OPV)- 10.5402 x WHO in+ 0.0770 x 50%kcal/h


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This method for prescription and modeling of programmedphysical activity is proposed since the relative risk is upper than 1

(RR>1).

The second model of the logistic regression shows the efficacy of

treatment and that is patients of PAD group are increasing the levelof HDL-C.

In this analysis are included 47 variables. As outcome variable is

HDL-C in the final phase of treatment. It's the most significant leading

change, confirmed mathematically with the equation:lnRR=11.834710.545 HDL-C fin

The results of this clinical trial are pointing to the significant of the

discovery of this variables.

The aim is the dividing of the group of risk patients with the

possibility developing complications related to obesity.


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CONCLUSION

Using our method for prescription and modelling of programmed

physical activity (PA) were achieved:

- significant greater reduction on T2DM and CVD risk in FAD (physical

activity and diet) group than those in D (diet) group

- enlarged types of PA- enabled safe performance and

- avoid the risk for cardiovascular events during the individually and

group,s exercising.

Broader application of the method for prescription and modelling of programPA on field is proposed at subjects and groups with:

- low level of cardiorespiratory fitness: 20 ml/kg/min VO2 for male

and 14.2 ml/kg/min VO2 for female

- increased/high risk for main NCD- insulin resistance/Sy X

- FAI%, sport,s recreation.


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REFFERENCES:

1. Karvonen M.: The effect of training on heart rate. A longitudinal study. Ann.

Med Exp Biol enk 1957; 35:307-317.

2. WHO, Energy and protein requirements. Geneva: WHO 1985 (WHO Techn. Rep.Series 724).

3. American College of Sports Medicine, Statements Position. The

recommended quantity and quality of exercise for developing and maintain

fitness in healthy adults. Med Sci Sports Exerc 1998;30:375-91.

4. Simovska V: The effects of programmed physical activity and diet therapyon some atherogenic risk factors associated with abdominal obesity. Doctoral

dissertation, University St. Cyril i Methodij, Medical Faculty, Skopje.

Bulletin 2001; 777:56 - 66,

5. Andersen KL, Madironi R, Rutenfranz J, Seliger V et al.: Habitual physical

activity and health, WHO Regional Publications European, Series No., Copenhagen

1978.

Book_WCPD 2008.Simovska Vera.MD.,PhD. Helsinki.

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