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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 for
increasing 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 were
applied: 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 next
content: CHO=54.1% (Poly CH=58.9%), P=26% and F=21.1% of total energy intake.
Using tables for gross energy expenditure of various physical activity with known energy cost (METs)
were chosen different type of physical activity in accordance with initial level of cardiorespiratory
capacity (VO2max), also expressed in term of metabolic equivalents (METs).
Results:
VO2max was increased for 14.8% in relation to the initial level of cardiorespiratory capacity in PAD
group. At this time, there were significantly greater decreases in the PAD group than those in the D
group in fasting plasma glucose, as well as in the HbA1c, % F, BW kg. and atherosclerosis indexes.
Conclusion:
T2DM can be prevented in high-risk truncal obese adult and elderly population using increasing VO2max
and specific macronutrient content of diets in accordance with our a proposal - a measure.
References:
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.
1
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.
www.cindi.makedonija.com
2
INTRODUCTION
Community situation
Environmental factors
3
OBJECTIVES:
4
MATERIAL AND METHOD:
The second phase was the increased energetic value of the diet for
200kcal/d CH=54.1%, (PolyCH=58.9%), P=26% and F=21.1% of
total EI).
5
BASIC FOOD GROUPS IN DAILY MAILS
- Ist AND IIth PHASE OF DIETO THERAPY
41
43
%45
40
35 30 21,4
30 17
22,54 23,14 14,5 18,26
25 16
20 13,67 17,37
5,7
15 9 1
10 6,84 1300kcal-WHO CINDI
0
5 1400kcal-IIth phase
0 1200kcal-Ist phase
0
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7
Tab-2. MICRONUTRIENT CONTENT OF DIETOTHERAPY
8
GRAF 1. FAT CONTENT (SFA, MUFA, PUFA) IN Ist AND IIst PHASE OF
DIET THERAPY, EXPRESED IN PERCENTAGE OF TOTAL ENERGY INTAKE/24h
%
35 30%
30 25.43%
20.83% 8
25
7,27
20
5,75
12
15
8,84
10 9,49
5 9,26 10
5,39
0
1 PHASE 2 PHASE AHA/EAS >2000kcal/d
9
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
90 90
80 40 80
47.22
70 56.29 70 58.87
70
60 75.03 60
50 50
40 40
30 60 30
52.78
20 43.71 20 41.13
30
10 24.97 10
0 0 merewa
1 etapa 2 etapa AHA/EAS
1 etapa AHA/EAS>2000kkal/d
>2000kkal/d
rastit.proteini `ivot.proteini mono-disaharidi polisaharidi
10
A proposal - a measure for increasing
cardiorespiratory fitness - VO2 max
11
METHODS FOR PRESCRIPTION OF PHYSICAL ACTIVITY
Special program <30%; 30-49% <5.6 m.; <4.3 f. <3.0 m.; <2.1 f.
PAL II
8.5-12.0 m. 4.5 - 7.0 m.
Exercise for 60-74%
6.8-10 f. 4.2 - 6.3 f.
fitness
Training for sport 75-84%; ≥85% >12 m.; >10 f. >7.0 m.; >6.3 f.
13
Tab-4. CLASSlFICATION FOR INTENSITY OF
PHYSICAL ACTIVITY/WORK EXPRESED
AS ENERGY EXPENDITURE (METs)
INTENSITY OF
METs-male METs-female PHYSICAL ACTIVITY/
(ANDERSEN) (WHO) WORK (METs)
14
Training for sport
Strenuous 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%
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 rate15
R E S U L T S:
16
Graf. 3 SUBJECTS DISTRIBUTION IN PHYSICAL ACTIVITY GROUPS
(PALs) - INICIAL AND FINAL RESULTS IN FAD GROUP
GROUP - "FAD"
%
INICIAL PHASE
60 55 FINAL PHASE
50
50
40
40
30 25
20
20
10
10
0 0
0
PAL I-ACTIVITY FOR PAL II-EXERCSE FOR SPECIAL PROGRAM TRAINING FOR SPORT
HEALTH FITNESS 17
Graf. 4 – BODY WEIGHT REDUCTION (gr/d ) IN Ist PHASE AND
FROM INICIJAL TO FINAL PHASE IN FAD AND D GROUP
0 I PHASE
0 0
-20
-40
-60 -112,43
-80
-100
p<0.000
-120
-140
-160 -176,54
-180
-200
BW0 gr/d FROM INICIAL TO FINAL PHASE
0 0
-20
-40
-60 -109,02
-80
-100 p<0.000
-120
-140 -152,13
-160
BW gr/d 18
FAD group D group
MANOVA
7
Graf 5. DESCRIPTIVE CHARACTERISTICS ON GLYCAEMIA (Glymmol/l) 6 6,17
5,29 5,19
IN INICIAL AND FINAL PHASE AND DINAMICS OF CHANGES 5
4,79
GLy-mmol/l 4
3 p0 <0.000
8 p1 >0.05
p>0.05 2
1
7 p>0.05
0 merewa
6,17 INICIJALNA FINALNA
GRUPA FAD GRUPA D
6 5,29 5,19
4,79
5 4,32 4,32
0
merewa
INICIJAL FINAL
GRUPA FAD GRUPA D GRUPA K
19
%HbA1c MANOVA
10%
9% p0<0.01
Graf 6. DESCRIPTIVE CHARACTERISTICS ON %HbA1c IN 8%
p1>0.05
6%
5.60 5.72
%HbA1c 5% 4.76
4%
10% 3%
2%
9% p>0.05 1%
0% merewa
INICIJALNO FINALNO
8% 7.10
GRUPA FAD GRUPA D
p>0.05
7%
5.60 5.72
6%
4.76
5%
3.78 3.78
4%
3%
2%
1%
0%
merewa
INICIJAL FINAL
3.5 3.38
1.5 p0<0.000
p1<0.01
LDLL-C/HDL-C
p>0.05 p<0.001 1
4 3,38 0.5
0
merewa
3,12 INICIJALNO FINALNO
3,5 3 GRUPA FAD GRUPA D
3
2,17 2,15 2,17
2,5
1,5
0,5
0
INICIAL FINAL
FAD group D group K group
21
Graf. 8 - Significant changes in level of VO2max and “major” risk
factors for T2DM and CVD between FAD (physical activity and diet) and
D (diet) groups of abdominal obese subjects 25 %
VO2max 20
17,1
14,8 15
HDL
10,4
%Fc-m 10
5,5
5
TT-I f TT %M LBM WHR OS LDL/HDL TC/HDL %FAI BMR
0 0 0 0 0
-1,8 VO2max -5
-3,5 -3,3 -3,3 OPV -3,1
-4,9 -5,3 -4,5 -5,6 -5,2
-6,3 -10
-7,9 -7,7
-9,5 -9,3
-10,3 -10,2 -10,2
-15
-20
-25
-30
-28,6 -27,7
FAD D
-35
22
LOGISTIC REGRESSION
Logistic regression was implement with aim to predict those regressors which with
their values as final result are giving a probability for selecting for either the group
PAD or the group D.
In the analysis are included 50 independent variables, and as outcome variable was
the group which signified the type of therapeutically treatment among our patients.
The first model of logistic regression shown in a form of equation gives dividing
the 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 VO2max–OPV (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 energy
expenditure (kcal/h) during PA with intensity of 50% HRmax reserve (VO2max).
Logistic model in form of equation is:
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.
24
CONCLUSION
25
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).