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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 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:

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 subspecialization
thesis, 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.
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.

At present, clinical researches of different branch of medicine,


exercise scientists, pharmacists, nutritionists, psychiatrists,
sociologists and many others are surprised with the fact that
finally 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 is
not possible to be applied as alteration for physical activity in
an integrated T2DM and CVD risk management.

Vera Simovska. MD., PhD.

www.cindi.makedonija.com
2
INTRODUCTION

 Numerous epidemiological, genetically and molecular


studies at different population worldwide confirmed that obesity is
associated with metabolic complications that increase the risk for
T2DM, CVD and other NCD. The complex of multifactor phenotype is
determined 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

3
OBJECTIVES:

1. To promote preventive-therapeutic programmes with a


proposal-a measure for macronutrient content of diets and
increasing cardiorespiratory fitness (VO2max) intended for
truncal 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 the
exercise and biological characteristics of subjects.

3. To estimate the efficiency of the method on T2DM and CVD


risk reduction at abdominal obese subjects included in 7wk
randomized controlled trial.

4. To construct a new index as mathematical model for predicting


the effects of non-pharmacological therapies at obese
population on average/increased and high risk for CVD and
other NCD.

4
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<15) and vitamin-mineral supplementation.

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

s
s

es
sta

ts
oi l

ui t
gg

uc

ak
pa

,
fat
,e

, fr
od

r, c
h
d,

l es
pr
fis

ga
ea

tab
iry
at,
br

su
da

ge
me

ve
l k,
mi

1200kcal-Ist phase 1400kcal-IIth phase 1300kcal-WHO CINDI 6


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).

Table 3. MACRONUTRIENT CONTENT

CINDI FOOD PYRAMID (WHO,, 1998)

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

FAT SFA MUFA PUFA

%
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

PROTEINI JAGLENI HIDRATI

25.28% 25.73% 16% %


% 49.27% 53.43% 60%
100 100

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

- 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 included


twice a week.

11
METHODS FOR PRESCRIPTION OF PHYSICAL ACTIVITY

1. The basic criterion for patient selection in four groups of


physical activity levels (PALs) was initial level of VO2max
expressed 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 was


expressed as energy expenditure in term of METs (Tab. 2).

6. 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).
12
Table 3. METHOD FOR PRESCRIPTION AND MODELLING OF
PROGRAMMED PHYSICAL ACTIVITY

Relative intensity % Classification of


Method Indicial level of
for prescription and modeling of programmed physical activity
Training pulse intensity of
HR max reserve
VO max
PAL-s groups 2
(METs)
physical activity
Karvonen M. (METs)

Special program <30%; 30-49% <5.6 m.; <4.3 f. <3.0 m.; <2.1 f.

PAL I 5.6-8.5 m 3.0-4.5 m.


Activity for health 50-59% 4.3-6.8 f 2.1-4.2 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)

< 3.0 < 2.1 LIGHT TO MODERATE


ACTIVITY

3.0 – 4.5 2.1 − 4.2 MODERATE

4.5 – 7.0 4.2 − 6.3 MODERATE TO


VIGOROUS

> 7.0 > 6.3 STRENUOUS


ACTIVITY

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%

Exercise for fitness and increasing performance


moderate 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 health


moderate 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 rate15
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 obese
patients included in 7 week randomized controlled trial.

Improved VO2max at 17.16% from baseline promoted


significant greater reduction on level of CVD risk factors in FAD
than 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 and
decreased at 9.3% in D group.

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

INICIAL AND FINAL PHASE AND DINAMICS OF CHANGES 7% 7.10

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

GRUPA FAD GRUPA D GRUPA K


20
LDL-C/HDL-
c MANOVA
4

3.5 3.38

Graf. 7- DESCRIPTIVE CHARACTERISTICS ON LDL− −C/HDL-C INDEX 3 3 3.12

IN INICIAL AND FINAL PHASE AND DINAMICS OF CHANGES 2.5


2.15
2

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:

ln“RR” = 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
23
 This method for prescription and modeling of programmed
physical 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 level
of 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:
ln“RR”=11.8347–10.545 · 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.

24
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 programm


PA 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.

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).

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 therapy


on 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.
26

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