Ex Phys Test 3

Front 1

approximately how many ppl who have survived an acute MI

Back 1

1 million

Front 2

great demand for cardiac rehab, but only a limited amount of rehab programs

Back 2

only about 1,000 in US

Front 3

if they survive,

Back 3

they are considered uncomplicated, they can benefit from cardiac rehab

Front 4

CABG

Back 4

coronary artery bypas graft
- most common elective surgical procedure in the US

Front 5

PTCA

Back 5

percutaneous transluminal coronary angioplasty
- transluminal means across the entire lumen

Front 6

CABG,PTCA, and angina patients are also

Back 6

uncomplicated

Front 7

cardiac rehab is beneficial and safe for MI, CABG, PTCA, and angina patients

Back 7

reduces mortality

Front 8

1 survey shows that 95% of physicians recommend cardiac rehab

Back 8

yea

Front 9

only 20% of people who have MI's are actually doing cardiac rehab

Back 9

yeh

Front 10

90% of cardiac deaths occur

Back 10

outside the hospital

Front 11

50 years ago cardiac rehab was

Back 11

bed rest, 30 day stay at hospital, oxygen, pain meds, and meds for arrythmias
- patients weren't allowed to return to work for 4 months
- exercise programs- mostly chair therapy (get up and sit down in the chair, repeat)
- patients had to consult physicians before they were allowed to walk

Front 12

in the 1970s, that changed

Back 12

- stay was cut in half
- many programs sprouted up
- North Carolina, California, Atlanta, Cleveland, Pennsylvania most notable

Front 13

what is cardiac rehab?

Back 13

-a multiple intervention (multi-phasic) program

Front 14

5 different components

Back 14

exercise therapy
psychological counseling and social interaction
vocational and recreational counseling
patient and family education
behavioral modification

Front 15

exercise therapy

Back 15

- should be effective
- encourage a change in lifestyle
- should be safe; most important

Front 16

psychological counselling and social interaction

Back 16

- i.e. some ppl just wanna die, some ppl really wanna live

Front 17

vocational and recreational counselling

Back 17

i.e. can i go back to work, can i go back to my kids; usually based on what the patient's functional capacity is

Front 18

patient and family education

Back 18

reduce likelihood of 2nd attack; also covers nutrition and blood lipid education

Front 19

behavioral modification

Back 19

i.e. smoking cessation

Front 20

types of patients

Back 20

valve patients, pacemaker, angina, recent MI, multiple risk factor patients, positive exercise stress test patients, CABG and PTCA patients

Front 21

within each one of these, they differ in terms of

Back 21

- severity of disease
- functional capacity
- s & s of disease
- lv function
- disease manifests itself differently in every person

Front 22

benefits of cardiac rehab

Back 22

- improved physiological function
- decreased stiffness after surgery
- reduced likelihood of atelectasis (pulmonary collapse due to poor lung volume)
- early hospital discharge
- decreased incidence of depression and anxiety

Front 23

safety in cardiac rehab

Back 23

- want to reduce likelihood of cardiac event

Front 24

risk for cardiac event is a function of 2 things

Back 24

- left ventricular function- measured by left ventricular ejection fraction (usually 50-60%); when a patient hits <30% then things can go bad
- myocardial ischemia- assess by ST segment depression, angina pain, inappropriate response in BP, inappropriate response in HR

Front 25

most cardiac problems in cardiac rehab occur during

Back 25

warmup or cooldown

Front 26

most rehab problems require a monitoring for a little bit before sending them home

Back 26

yea

Front 27

a good post exercise surveillance period is a good thing

Back 27

word

Front 28

other reasons for cardiac events during exercise

Back 28

exceeding the target heart rate range

Front 29

cardiac rehab is divided into 4 phases

Back 29

inpatient phase, outpatient phase, community based program, home based program

Front 30

inpatient phase

Back 30

begins as soon as patient is stable, usually within a couple days after surgery

Front 31

typically done with a

Back 31

physical therapist

Front 32

usually involves

Back 32

EKG monitoring

Front 33

goals are to get patient to do

Back 33

activities of daily living (ADL)

Front 34

provide them with some education

Back 34

yea

Front 35

do exercises that are gonna offset the effects of bed rest or surgery

Back 35

ye

Front 36

increase ROM

Back 36

and emphasis on muscle tone

Front 37

inpatient usually lasts

Back 37

2-3 weeks; target is 10-15 beats above standing resting heart rate
- patient should be taught about contraindications of exercise and how to tell when they shouldn't exercise
- duration is short, multiple sessions per day

Front 38

patient staff ratio

Back 38

1:1
- highly individualized
- medically supervised

Front 39

outpatient phase

Back 39

- usually occur within a medical setting; some sort of clinic

Front 40

usually a physician is in attendance or on call

Back 40

ye

Front 41

patient staff ratio

Back 41

5:1 (but usually ends up being more)

Front 42

usually use telemetry

Back 42

- put the electrodes on, electrodes are sent by air to get an ECG of them

Front 43

outpatient phase should begin when

Back 43

as soon as the person is discharged from the hospital

Front 44

take bp during exercise

Back 44

ye

Front 45

lasts up to

Back 45

3 months; 3 sessions a week
- make sure the exercise is safe

Front 46

typically higher in terms of hr

Back 46

- usually 20-30 beats above standing resting hr
5-10 beats below ischemic threshold or below any disrhythmia that occurs

Front 47

types of exercise

Back 47

walking, jogging, or cycling; dont swim

Front 48

duration

Back 48

once duration reaches 30-40 min, its prob time to discharge the patient

Front 49

strength training

Back 49

you can do it for large muscle groups, but not small ones; avoid hand gripping- it raises bp dramatically; no situps or pushups
- usually before changing the workload, they should be able to do it a couple times a week
- keep the intensity low, and keep emphasis on the duration

Front 50

patients are then discharged; no criteria really, but patients should have a functional capacity of at least 5 min

Back 50

- no hemodynamic issues
- should have a stable medical status
- should be able to maintain exercise intensity appropriately (should be able to monitor themselves)
- should be pretty functional, not too many issues
- they should know about their meds and their side effects
- should know about their activities
- should know about their recreational pursuits (i.e. if they can come back to work or not)
- should know if they can go back to sexual activity. max stress during is 4-6min; an orgasm lasts 15-20 sec. usually average hr is 115-120bpm. sometimes issues related to arryhthmias happen after orgasm
- if u can walk 2 flights of stairs, or take a brisk walk, then ur OK

Front 51

community based program

Back 51

- places like YMCA

Front 52

admission includes

Back 52

physical exam and medical history, risk factor assessment, physician referral, graded exercise test no more than 3 months old

Front 53

community based programs usually have a

Back 53

defibrillator, along with emergency drugs and equipment
don't need a physician present; but there's usually a paramedic or a cardiac nurse there

Front 54

ppl that come to community based programs

Back 54

- ppl who have been thru a cardiac rehab program before
- ppl who have risk factors but haven't had an event yet

Front 55

staff to patient ratio

Back 55

1:15 (usually 1:25ish tho)

Front 56

entrance criteria

Back 56

must be able to do 5 METS
- must be able to self regulate exercise
- must have arrhythmias under control
- must have knowledge of over exertion
- ability to judge perceived exertion
- must be clinically stable

Front 57

special attention given to clients

Back 57

- must be motivated to exercise

Front 58

initial exercise intensity

Back 58

70%

Front 59

activities include

Back 59

- everything from walking, cycling, swimming;
- often times there's volleyball (not too competitive); often times patients in community based programs have a Holter monitor. Records electrical activity in the heart

Front 60

defibrillator often used to get a quick recording of the patient

Back 60

maybe

Front 61

no routine monitoring of patients

Back 61

ye

Front 62

strength/flexibility programs are important

Back 62

- static activities or very resistant exercise are not recommended

Front 63

home based program

Back 63

- not that great bc most ppl wont do it while they're home
- not really effective
- hard to follow up on it (mayb thru a phone call or something)
-

Front 64

once you've reached 300 calories per session 3 times a week

Back 64

then u can move on and ur done w cardiac rehab; cardiac rehab is usually a year to a year and a half
- lastly, for cardiac patients, you occasionally get patients who are doing things like marathons and other events and can perform far more intense exercise than the other patients

Front 65

ischemic threshold

Back 65

x axis- workload
y axis- RPP
- as workload increases, RPP increases, but at a certain point, RPP stops increasing, indicating ischemic threshold
- on EKG st segment depression 2mm for .08s is significant

Front 66

cardiac rehab makes it so that you need more workload to hit that ischemic threshold

Back 66

ye

Front 67

importance of knowing ischemic threshold

Back 67

- u exercise a person 10 bpm less than their ischemic threshold
- dont go to ischemic threshold bc then myocardial ischemia starts

Front 68

sudden cardiac death during exercise

Back 68

- death within 6 hours after an arrest, in what appears to be a healthy person
- in sport, this death usually occurs within minutes
- non violent, nontraumatic, unexpected
- mostly in basketball and football in males
- incidence increases with age

Front 69

how many ppl a year die from sudden cardiac death

Back 69

50 ppl; 15,000 ppl die in motor vehicle accidents annually
- 1 in 15,000 joggers die for older population
- in adolescents its 1/250,000 joggers

Front 70

commotio coardis is not sudden death

Back 70

- when u hit someone at the right time in the heart during the refractory period, before the t completely repolarizes, you can stop the heart

Front 71

dividing groups into older and younger (<age 40= young)

Back 71

ok

Front 72

younger group dies after super exertion for 4 reasons

Back 72

hypertropic cardiomyopathy- enalrged interventricular septum
conenital anaomalies of the coronary arteries
a rupture of the aorta- a weaking of the aorta
aortic stenosis- a thickening of the aortic valve
- most cases in younger athletes are asymptomatic

Front 73

in sudden death in older people >40 its usualy

Back 73

CAD
- usually 75% narrowing in 3 vessels
- may or may not have a previous MI. usually they appear in excellent physical condition. some may have been exercising for years. they often have prodromal symptoms (initial stages) but you dont know what's wrong.

Front 74

Jim Fixx

Back 74

wrote the complete book of running. died at age 52, had a previous history of smoking; cholesterol was 254, had a family history of CAD

Front 75

recommendation

Back 75

- any male over age 45 should get a stress test

Front 76

Bassler

Back 76

pathologist who did autopsies on ppl who died suddenly during exercise; believed you could train yourself out from sudden cardiac death
- didn't take into account ppl who start exercising when they're old; mostly geared toward ppl who have been exercising when they were young

Front 77

when u exercise, the risk is greater than if u were sedentary

Back 77

yeah
- dont exercise when ur sick

Front 78

ejection fraction

Back 78

sv/edv
- after ejection, like 30-40ml left in ventricle; like 80 is released; like 60% total is released

Front 79

damage to left ventricle and what happens in terms of ef

Back 79

- if the damage is mild, the ef is a little less, maybe 5-10%
- an ef of 30% gives u a mortality rate of about 80%
- severe damage >25% is effective
- moderate damage is around 25% of the heart
- most people who die, die from an electrical problem

Front 80

under 30 or under 40

Back 80

usually CAD is the cause

Front 81

hypertropic cardiomyopathy

Back 81

- the most common cause of sudden death in young athletes
- 1/2 of all cases
- characterized by unexplained dramatic ventricular thickening, particularly of the interventricular septum
- the left ventricular cavity is non dilated, so this thikcening can cause an outflow, filling probs, and emptying probs
- cause ECG abnormality

Front 82

possible causes for HCM

Back 82

- inadequate blood flow to coronary arteries (outflow problems)
- insufficient filling of the ventricles
- disturbances in the electrical activity

Front 83

HCM is an inherited condition

Back 83

- gene problem associated with the myosin molecule
- positive family history in 20% of the cases
- physical exam is typically normal

Front 84

more HCM

Back 84

- ecg is abnormal but u cant really tell what it is
- the definitive clinical test for HCM requires an echocardiogram, then you can really tell if u have HCM
- about 1/2 the ppl who have HCM have some sort of symptom; i.e. chest pain, breathlessness with exercise

Front 85

HCM diagnosis

Back 85

diagnosed with thickness of the interventricular spetum being 18mm thick or greater
- along with a smaller cavity
- if u really wanna see if someone has HCM, stop exercising for 30 days, then get an echocardiogram and check for septum thickness. If the thickness goes away, then they don't have HCM

Front 86

ventricular fillings

Back 86

- abnormal amount of ventricular fillings when u have HCM

Front 87

biphasic pulse

Back 87

- u have a biphasic pulse when u have HCM

Front 88

coronary artery anomalies

Back 88

- pete pistol maravich
- didnt have a left coronary artery (aka widowmaker)
- his right coronary artery helped get some blood to the left ventricle
- anomalies include: abnormal origin from the aorta, incomplete development of coronary arteries, coronary arteries that like deep within the muscle
- end result is always an insufficient blood supply to meet the demands
- most common result: sudden collapse and death
- usually happens in apparently healthy person; Pete was only 40

Front 89

rupturing of the aorta

Back 89

another cause of sudden death
- there's a dilated base of the aorta
- blood gets in bw the tissue layers and starts to pull them apart
- it is a laxity of the connective tissue; the conective tissue lacks integrity; a protein is missing that would make the tissue stronger

Front 90

unlike coronary anomalies, there are some other things that will tip u off to having this

Back 90

- if u have an armspan greater than ur height
- a tall stature
- hyerextensible joints
- spinal curvature
- pectus excavatum (sunken chest)
- flat feet
- abnormalities of the eyes including nearsitedness (myopia)
- dislocated lenses
- regurgitation of the valves- mitral valve prolapse- papillary muscles don't hold valve tight enough and regurgitation occurs
- dilated aorta
- you can have combinations of these
- very long, skinny fingers
- progressive widening of the aortic route
- eventually, may have an aortic anurism
- happens in both men and women

Front 91

what do u do for these people?

Back 91

- usually use beta blockers
- surgery to narrow the aortic route; critical diameter is 60mm
- sometimes they can put a tephlon piece in there
- usually avoid resistance training or very high intensity exercise
- also, avoid anything that would give the possibility of a blow to the chest

Front 92

abe lincoln was said to have marfan's syndrome

Back 92

ye

Front 93

diabetes stuff

Back 93

aight

Front 94

we consume 500 less calories than we did in the 20th century, but we are more overweight nowadays

Back 94

prob an activity factor

Front 95

diabetes mellitus

Back 95

- disorder of blood sugar regulation; a carbohydrate metabolism problem
- diabetes= excess urination
- mellitus= sweetness

Front 96

one of the symptoms of diabetes

Back 96

when glucose is dumped into the urine

Front 97

the use of exercise for diabetes has been around for a while

Back 97

as early as 600BC

Front 98

exercise for diabetes got popularized prob around 1900s by a diabetologist named Joslin

Back 98

yeah

Front 99

exercise is prescribed as part of the treatment

Back 99

secondary to insulin, but is still a really important part of the treatment

Front 100

primarily a problem with glucose

Back 100

glucose- most important carb in the body
- blood glucose is very well regulated (typically 100mgs% per 100ml blood)
- 90-120 is normal range

Front 101

even after a prolonged fast

Back 101

ur blood glucose seldom drops below 60mgs%

Front 102

if it drops below 60

Back 102

ur hypoglycemic

Front 103

below 75mg%

Back 103

will affect athletic performance

Front 104

160mg%

Back 104

marker for glucose being dumped into the bloodstream

Front 105

following a meal

Back 105

ur blood glucose rises below normal; 20-30 min following a meal, ur blood glucose is back to normal

Front 106

glucose used by

Back 106

brain, skeletal muscle, heart, nervous system, adipose tissue

Front 107

what is the only organ capable of releasing glucose into the bloodstream

Back 107

liver

Front 108

people with liver issue end up with

Back 108

glucose metabolism problems

Front 109

enzyme used

Back 109

phosphatase
- phosphatase breaks off the phosphate from glucose 6PO4 inside the cell
- glucose 6 phosphate is a bigger molecule than glucose so it is trapped inside the cell; by adding phosphate
- glucose 6 phosphate is the first molecule in glycolysis- once its inside the cell, it stays inside the cell- the only way it gets out is if phosphatase cleaves off the phosphate

Front 110

equation

Back 110

G6P-->glucose-->glycogen

Front 111

symptoms of diabetes

Back 111

- polyuria- excess or frequent urination
- polydipsia- unusual thirst
- polyphagia- eating abnormally large amounts of food; hunger
- unusual rapid weight loss
- extreme fatigue, drowsiness, irritability
- frequent infections
- cuts or bruises that are slow to heal
- blurred vision
- tingling or numbness in the hands and feet
- skin, gum, or bladder infections

Front 112

types of diabetes

Back 112

i and ii
- characterized by high blood glucose

Front 113

type i

Back 113

- insulin dependent diabetes mellitus (IDDM)
- typically requires exogenous insulin
- characterized in obese kids; childhood or juvenile

Front 114

type ii

Back 114

non insulin depdendent diabetes mellitus (NIDDM)
- does not typically require insulin
- characterized by adult obesity, but still seen in some obese kids
- characterized by insulin sensitivty decrease in cells
- characterized by an excess concentration of insulin in the blood
- requires detary modification, exercise, and some sort of medication to reduce blood glucose
- only time exercise is not recommended is when someone has uncontrolled diabetes

Front 115

diabetes is the 2nd leading cause of death

Back 115

yea

Front 116

#1 cause of blindness in ppl age 20-74

Back 116

ye

Front 117

diabetic retinoapthy

Back 117

microvascular disease
- microvascular disease can also occur in the kidneys, known as nephropathy

Front 118

there are more type ii than type i diabetics

Back 118

yea; 90% are type ii

Front 119

diabetics is more common in what races

Back 119

native americans, hispanics, and african americans

Front 120

estimated that a little under 20 million americans have diabetes

Back 120

1/3 do not know they have the disease

Front 121

in addition to having microvascular disease, diabetics can also have

Back 121

macrovascular diseases

Front 122

neuropathies

Back 122

nervous problems; tingling or numbness in hands or feet

Front 123

middle age death rates for ppl w diabetes is..

Back 123

twice that of ppl without diabetes

Front 124

more than 15% of ppl who have diabetes under age 30 will die by age 40

Back 124

that is 20x the normal rate of death

Front 125

over 100 billion dollars a year spent related to diabetes

Back 125

ye

Front 126

when u say diabetes, most of the time it refers to

Back 126

diabetes mellitus; but theres also diabetes insipidus

Front 127

diabetes insipidus

Back 127

- problem with pituitary gland
- it doesn't secrete adequate ADH
- as a result, you have polyuria
- relates to dehydration, extreme thirst
- inadequate levels of ADH

Front 128

4 categories of diabetes

Back 128

type I, type II, Gestational, Miscellaneous

Front 129

type I

Back 129

- juvenile; insulin dependent
- occur abruptly before age 30
- auto immune problem- ur body 'self destructs' in a way
- absolute insulin deficiency
- insulin injection or insulin pump

Front 130

pancreas is made of 2 types of tissues

Back 130

- acini and islets of langerhans

Front 131

islets of langerhans

Back 131

- have alpha, beta, and delta cells
- alpha- produce glucagon
- beta- most abundant, mostly located in the cortex
- delta- produce somatostatin
- somatostatin- puts brakes on insulin secretion

Front 132

pancreas is an endocrine gland

Back 132

endocrine- refers to internal secretion; secretes directly into blood
exocrine- external secretion to skin; i.e. sweat glands

Front 133

in some cases, type I is idiopathic or agnogenic

Back 133

unknown cause

Front 134

type II diabetes

Back 134

insulin resistance in the adipose tissue, the skeletal muscle, and the liver OR there might be a secretory defect- pancreas may not secrete enough insulin

Front 135

how many % of cases are type II

Back 135

90%

Front 136

in 20% of the cases of type II

Back 136

its similar to type I- you have an immune mediated beta cell destruction; this might occur over several months, over even years

Front 137

type II ppl may be using insulin every once in a while

Back 137

ye

Front 138

common characteristic in type ii

Back 138

fat in the trunk (excess central adiposity)

Front 139

type ii typically occurs when

Back 139

after age 40
- progressive problem, where pancreas could secrete enough at one point, but then slowly becomes less able to

Front 140

type ii is increasing in terms of adolescents

Back 140

as early as 6 years of age as a result of obesity

Front 141

type ii increases with..

Back 141

age, lack of physical activity, and a history of gestational diabetes

Front 142

genetic component for type ii

Back 142

kids who come from parents w type ii diabetes are twice as likely to get it

Front 143

80% of type ii diabetics are

Back 143

obese or overweight

Front 144

for men and women waistlines

Back 144

men- over 40 in
women- over 35 in

Front 145

prediabetes

Back 145

some insulin resistance, some degree of obesity

Front 146

1.5 million new cases of diabetes every year

Back 146

yea

Front 147

over 100 billion dollars spent on diabetes a year

Back 147

yea

Front 148

gestational diabetes

Back 148

5% of all pregnancies result in gestational diabetes
- usually diagnosed in second trimester

Front 149

risk factors

Back 149

- family history
- if mother is obese
- if baby weighs more than 9 lbs

Front 150

50% of women w gestational diabetes will develop type ii diabetes within 10 years

Back 150

ye

Front 151

more symptoms

Back 151

- relatively inadequate insulin secretion
- some have a problem with insulin response

Front 152

the baby can have

Back 152

macrosomia- large birth weight

Front 153

the baby can suffer

Back 153

- respiratory distress
- congenital cardiac and CNS anomalies
- skeletal muscle malformations
- perinatal death- before, during or 7 days after, the baby dies

Front 154

characteristic of all the diabetes

Back 154

hyperglycemia

Front 155

miscellaneous diabetes

Back 155

- characterized by hyperglycemia
- 2% of all cases
- may or may not require insulin treatment

Front 156

causes of miscellaneous diabetes

Back 156

- diseases
- injuries
- infections
- medications
- drug use
- genetic syndromes

Front 157

LADA

Back 157

- latent autoimmune adult diabetes
- its a type I diabetes for adults

Front 158

MRDM

Back 158

malnutrition related diabetes mellitus
- poor diet, in particular high fat diet

Front 159

steroid induced diabetes mellitus

Back 159

glucocorticoid diabetes mellitus

Front 160

there is also diabetes related to cystic fibrosis

Back 160

yea

Front 161

insulin stuff

Back 161

ye

Front 162

insulin

Back 162

peptide hormone made of 2 polypeptide chains

Front 163

who determined the amino acid sequence

Back 163

Sanger

Front 164

since the sequence was established, it could be chemically synthesized

Back 164

yea

Front 165

the activity of insulin is related to its

Back 165

conformation (the 3d structure of the hormone

Front 166

you can change the amino acid sequences of it, and when you do..

Back 166

you change its conformation, therefore changing its activity; there's lots of variations

Front 167

insulin is also secreted in response to

Back 167

calcium

Front 168

the secretion of insulin has 2 phases

Back 168

- rapid phase- dependent on insulin that's already present in the pancreas
- slow phase- dependent on insulin that's newly synthesized

Front 169

maximum stimulation in terms of secretion is less than 10%

Back 169

i.e. less than 10% of whats in the pancreas is secreted

Front 170

tolbutamide

Back 170

- stimulates insulin secretion

Front 171

cyclic AMP

Back 171

- works in conjunction with glucose in terms of insulin secretion; its an intracellular messenger

Front 172

insulin is usually a part of the steroids

Back 172

its very anabolic; affects muscle, adipose tissue, heart, liver

Front 173

insulin effects

Back 173

- decreases blood glucose
- increases glycogen storage
- increases fatty acid uptake
- increases amino acid uptake
- inhibits release of glucose from liver

Front 174

metabolic syndrome

Back 174

combined hypertension, dislipidyemia, and diabetes

Front 175

how are you diagnosed w diabetes?

Back 175

- fasting blood glucose >125mg% (fasting= haven't eaten for 8 hours); usually taken on more than one occasion
-

Front 176

con't: if you have a 2 hour blood glucose >200mg%

Back 176

take 75g of glucose in water, wait 2 hours, if glucose is higher than 200mg%= bad
- caled glucose tolerance test

Front 177

iif you have casual blood glucose >200mg% measured any time of day regardless of when u last ate

Back 177

ye

Front 178

typical fasting blood glucose

Back 178

90-110

Front 179

impaired fasting glucose

Back 179

110-125

Front 180

after u eat a meal

Back 180

u get up to 160-180mg%, but in 30 min ur back to normal

Front 181

impaired glucose tolerance test

Back 181

values bw 140-199 are considered to be impaired glucose tolerance test

Front 182

renal threshold for glucose

Back 182

170mg%

Front 183

if u pee in a cup and theres glucose in it

Back 183

u have at least 170mg%

Front 184

when glucose gets dumped into the urine its called

Back 184

glycosuria

Front 185

stages of diabetes

Back 185

can be anything from pre diabetic to full blow diabetes; progressive

Front 186

american diabetes association has some guidelines from a prevention standpoint

Back 186

k

Front 187

everybody over 45 should have their glucose measured every

Back 187

3 years

Front 188

for certain ppl, it should be measured more often

Back 188

- if u have a bmi >27
- if u have a first degree relative w diabetes
- if u r a member of a high risk population
- if u have a baby that weights more than 9 lbs or gestational diabetes
- if ur bp is >140/90
- if ur hdl is <35 and triglycerides >250
- if u have a history of an impaired fasting or impaired glucose tolerance test

Front 189

hemoglobin a1c

Back 189

lab test that indicates the average amount of glucose in the blood over the last 3 months
- also called glycated hemoglobin or glycosolated hemoglobin

Front 190

normal a1c values

Back 190

4-5.9%

Front 191

hemoglobin is exposed to plasma glucose. as a result, the hb picks up a bit of the glucose. hemoglobin is a 4 polypeptide structure

Back 191

yes

Front 192

as glucose goes up

Back 192

hb a1c goes up

Front 193

american diabetes association says that if hb a1c is greater than 7%, then its diagnostic for diabetes

Back 193

- american college of endocrinology and international diabetes association says 6.5%
- at 6%, a1c represents a blood glucose of 126mg% (>125 is bad)
- at 7%, hb a1c represents a blood glucose of 154mg%
- generally, keep it lower than 7%

Front 194

of the 4 criteria for diagnosing diabetes, ADA recommends fasting blood glucose

Back 194

- a good way to monitor blood glucose
- excellent way to reduce risk of other problems associated w diabetes

Front 195

complications associated w diabetes

Back 195

- acute and chronic complications

Front 196

3 acute complications

Back 196

hyperglycemia, hypoglycemia, ketoacidosis

Front 197

hyperglycemia

Back 197

- high blood glucose levels
- can reach >300mg%
cutoff for exercise participation is 300mg% on high end or 100mg% on low end; to fix low end, have them drink some liquid carbs, and measure again in 20-30 min then send them
- its never a problem giving a carbohydrate, but u shouldn't administer insulin
- lack of sufficient insulin or too high insulin resistance results in fatigue, thirst, frequent urination, weakness
- treatment- insulin given by medical professional; sometimes bicarbonate if pH is too low

Front 198

hypoglycemia

Back 198

- when glucose <60mg%

Front 199

causes

Back 199

- excess insulin
- hypersecretion of insulin
- poor diet
- exercise induced problem
- injection site for the insulin
- most injections are in the abdomen

Front 200

more hypoglycemia

Back 200

- most common complcation associated w diabetes and exercise
- more common in type i diabetes
- an acute complication
- when blood glucose drops below 60mg%
- inadequate glucose supplied to brain

Front 201

immediate hypoglycemia

Back 201

- appears suddenly and rapidly
<60mg%
- treatment- 10-15g of a sugar, best given as a liquid as opposed to a solid
- food should be a high glycemic index i.e. sugar cubes, hard candy
- chocolate not good bc of fat (which lowers glycemic index)
- rest 10-15 min to allow for absorption of glucose
- blood glucose should be taken and if its above 100 , they can exercise
- during exercise, it should be assessed again every 30 min
- after exercise, you go back to complex carbs
- often times, patients are not aware of hypoglycemia
- hypoglycemic unawareness- they are unaware due to an ANS neuropathy

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late onset hypoglycemia

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- can occur 4 hours after the exercise to 2 days after the exercise
- occurs more frequently in ppl who are just starting exercise programs
- occurs in ppl who are doing too much
- usually need some sort of adjustment in their insulin

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hypoglycemia symptoms

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- extreme symptoms- unresponsiveness, unconsciousness, coma, convulsions
- mild symptoms- trembling, shakiness, nervousness, rapid heart rate, palpitations, increased sweating, excessive hunger
moderate symptoms- headache, irritability, mood changes, impaired concentration and attentiveness, mental confusions, drowsiness

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hypoglycemia treatment

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short term- carbohydrate
long term- adjustment in insulin; ur more likely to have hypoglycemia if u inject insulin into the muscle that is doing the exercise

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ketoacidosis (ketosis

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a result of the accumulation of ketone bodies

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3 ketone bodies

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acetone, acetoecetic acid, bethydroxybutyric acid

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ketone bodies are produced from

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AcoA in the mitochondria of hepatocytes

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ketonemia

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when the rate of synthesis exceeds their utilization

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ketonuria

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spilling of ketones into the urine

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ketonuria + ketonemia

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ketosis

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ketone bodies can be used for energy

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typically transferred from the liver to other tissues for energy

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after 4 days of low carb intake

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70% of energy comes from ketone bodies

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ketones have been linked to improved cognitive function (ketones are associated w omega 3 fatty acids)

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ye

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to balance pH when it is unbalanced due to ketoacidosis,

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the kidneys excrete glucose and ketones; the water follows the glucose and the ketones and that causes dehydration

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as a result of diuresis (excessive urine production)

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dehydration, hypertension, tachycardia

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ketoacidosis can be potentially fatal

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yeah

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in a type i diabetic, any type of biological stress, like an infection, the stress of exercise, can lead to ketoacidosis

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yea

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patients who have ketoacidosis have rapid deep breathing

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kussmaul breathing
- altered consciousness

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acetone is volatile

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- u breathe it out
- sweet, fruity odor (due to acetone)
- if it builds up too much and is not excreted thru breath, it is converted to acetoacetic acid and pH is lowered

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ketones have a negative effect on Pyruvate Dehydrogenase (PDH)

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- shut down ACoA
- but have a positive effect on pyruvate decarboxylase
- when glucose during glycolysis reaches the pyruvate acid stage, pyruvate can be converted to A CoA or Oxacoacetic acid
- if u dont need anymore A CoA, ketones shut down PDH (PDH converts pyruvate to A CoA
- ketone bodies stimulate pyruvate decarboxylase to make OAA
- citric acid cycle --> 1A CoA + 1 OAA
- to run the citric acid cycle, you have plenty A CoA, so the ketones stimulate production of OAA to make the citric acid cycle efficient. you can get rid of excess A CoA this way too

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so, you can get rid of excess acetone thru

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- breathing it out, urine, or burned for energy

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anaplerotic reaction

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citric acid cycle (1 of each to start reaction)
- 1 mg/dl is typical ketone value in bloodstream
- ppl on low carb diets end up using a lot of fat for energy
- low carb dietes can result in nutritional ketosis (bw 1-5mg/dl ketones)

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26% of US population 20 years and older have diabetes

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ye

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34% of population older than 60 has diabetes

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yea

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1/3 of all new cases are under age 20

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ye

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incidence of diabetes has more than tripled in recent years

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ye

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every 10 seconds a person dies from diabetes

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ok

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4th leading cause of death by disease, globally

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k

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20% of ppl who die from diabetes

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die from renal failure
50% of ppl die from cvd

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type ii diabetes decreased life by 5-10 yrs

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if u have type ii- twice as likely to suffer MI or stroke

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type i

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- autoimmune destruction
- t cells (type of wbc) attacks the beta cell

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diabetes literally means

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to pass thru
- urine passes thru= excess urination
Galen called it dirrhea of the urine (Diarrhea urinosa)

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mellitus

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means honey
- bc they have sweet urine

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insulin

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- secreted when blood glucose goes up
- insulin goes in blood and goes to target cells that are throughout the body
- if ur lucky, insulin binds to receptors that are on the cell surface
- the insulin binds with receptors, and as a result, the receptor moves glucose transporters from vesicles on one side of the cell membrane to the other
- when it goes to the other side of the membrane, it enables glucose to be transported in

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theres 13 types of glucose transporters; 3 classes, but we are only interested in 2 found in the first class

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- glut 1- found throughout the body, dependent on insulin
- glut 4- transporters found in adipose and skeletal muscle; insulin independent; operates independent of insulin

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what exercise does is

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it helps to reshape the insulin receptor so it can hook up to insulin and it can help with glut 4 in terms of lowering blood glucose levels

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risk factors for type ii diabetes

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- age >40 with at least one other risk factor
- sedentary lifestyle
- family history of diabetes
- ethnicity- Hispanic, American Indians, African Americans
- obesity- central abdominal obesity (40 inches for males, 35 inches for females)
- impaired glucose tolerance test
- high triglyceride levels

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more type i stuff

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- typically happens before age 20, need some exogenous insulin
- equally distributed bw males and females
- some evidence of a genetic component for type i
- usually has a rapid onset as opposed to type ii which is slow to come on
- medical emergencies are more common in type i than type ii (diabetic coma- usually due to ketoacidosis in type i diabetes)

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Diabetes Treatment

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- goal is to lower blood glucose levels
- currently no cure for diabetes
- it can be managed tho

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managing diabetes

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- exercise, nutrition, self glucose monitoring, education, medication
- few chronic disease require the same level of being actively engaged. Diabetics really need to be active in their treatment

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from a nutrition standpoint

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- reduce sat fat intake to <10%
- keep polyunsaturated fats to 10%
- limit cholesterol intake to around 300mg daily
- avoid simple sugars and replace w complex carbs
- intake has to closely match expenditure
- timing and regularity of meals is important

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medications for type i

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- insulin and/or hypoglycemic agents
- given subcutaneously
- in an acute care situation, you may get it thru IV

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3 types of insulin

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rapid acting
intermediate
long lasting

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medications for type ii

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- some sort of medication that would stimulate insulin secretion; oral hypoglycemics
- sulfonylurea medications- first type of meds used for type ii; fast acting, stimulate insulin secretion. problem: encourage as much as 10lb weight gain and increase risk of hypoglycemia

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alpha glcosidases

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- meds that decrease the absorption of glucose in the GI tract, decrease the digestion of glucose;
- dosing is a problem (how much to take)
- sometimes they decrease triglycerides

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glitazones (thiazolideendions)

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- increase the sensitivity of the target organs; so it works against insulin resistance
- problems- encourage up to 10lb weight gain
- heart failure is an issue
- higher risk of edema
- increased LDL
- expensive
- increase risk for fractures

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metformin

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- makes favorable changes in insulin resistance
- GI problems
- low risk of hypoglycemia
- lower LDL
- lower triglycerides
- no weight gain
- no real negative; except GI problems

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these meds that work on insulin resistance can reduce hemoglobin A1C by up to

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2%
this is glitazones and metformin

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the only time exercise is not recommended

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when the diabetic is poorly controlled

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exercise should be continuous

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moderate around 30-40 min 3-4 times a week; high intensity is not usually recommended

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diabetics should eat 1 1/2 to 2 hours before exercise

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ye

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if the exercise is more than 40 min

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you should supplement at 20-30min intervals
- resistance training should be encouraged in the absence of contraindications i.e. retinopathy

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if you have a diabetic patient w 2 or more risk factors

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its a good idea to have an exercise test

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autonomic neuropathy can lead to

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chronotropic incompetence
- as a result of diabetes, ur nervous system does not make the kind of adjustments that it normally would
- i.e. what you have is a heart rate that doesn't go up the way it should
- i.e. your bp doesnt go up
- i.e. attenuated VO2 kinetics; VO2 doesn't respond the way it should
- use a RPE to test for autonomic neuropathy

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diabetes patients often fail to detect ischemia

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look for ST segment changes

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most of the time what happens to treat diabetes is to use meds first, then lifestyle change; a common problem is hypoglycemia when u mix the two

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k

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SPECIAL CONSIDERATIONS

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ohk

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hypoglycemia is relative

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i.e. some ppl may not have symptoms at 80mg%, some ppl do
- blood glucose monitoring before and after exercise when ur starting out

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if u inject insulin into a muscle area thats gonna be exercised

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ur at risk for hypoglycemia
- most commonly injected into abdomen, sometimes arm

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take proper care of feet to prevent blisters

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- consider non weight bearing activities

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cross training

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- good idea; a group of training i.e. for endurance exercise, theres running, elliptical, cycling
- get good quality footwear

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more considerations misc

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- always have some extra food
- should have a diabetic bracelet
- good idea to carry some change
- take care of any injury you have, any abrasion
- exercise with somebody else