weeks 4-6
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Questions and Answers

Which of the following cytokines is NOT positively associated with triglycerides and total cholesterol?

  • TNF-a
  • Adiponectin (correct)
  • Leptin
  • IL-6

    • What is the role of IL-6 in the liver?

  • Increases the production of adiponectin
  • Regulates the production of triglycerides
  • Stimulates the production of C-reactive protein (CRP) (correct)
  • Inhibits the production of C-reactive protein (CRP)

    • What is widely thought to occur as a result of obesity and insulin resistance?

  • The development of chronic diseases
  • The improvement of cardiometabolic health
  • The suppression of hepatic glycogenolysis and gluconeogenesis
  • The clustering of multiple risk components within the metabolic syndrome (correct)

    • What is the association between high sensitivity C-reactive protein (hs-CRP) and ASCVD?

    <p>Robust association</p> Signup and view all the answers

    What happens in a healthy, insulin-sensitive person when glucose stimulates the release of insulin from pancreatic beta cells?

    <p>It reduces plasma glucose concentration</p> Signup and view all the answers

    What is the effect of vigorous physical activity on hs-CRP levels?

    <p>Decreases hs-CRP levels</p> Signup and view all the answers

    What is a chronic failure of insulin to maintain?

    <p>Glucose homeostasis</p> Signup and view all the answers

    What has been controversial in the development of the metabolic syndrome?

    <p>The role of insulin resistance</p> Signup and view all the answers

    Which of the following is NOT a proinflammatory cytokine?

    <p>Adiponectin</p> Signup and view all the answers

    What has research confirmed a pathophysiologic link with?

    <p>Insulin resistance and ASCVD</p> Signup and view all the answers

    What is the effect of TNF-a and IL-6 on insulin signalling?

    <p>Interfere with insulin signalling</p> Signup and view all the answers

    What has been linked to metabolic syndrome in both animal and human models?

    <p>Systemic inflammation, oxidative stress and endothelial dysfunction</p> Signup and view all the answers

    What is an independent risk factor for insulin resistance, hyperglycaemia, hypercholesterolaemia and hypertension?

    <p>Obesity</p> Signup and view all the answers

    At what stage do gradual decreases in cardiometabolic health start to occur?

    <p>Long before an individual reaches obesity or is diagnosed as insulin resistant</p> Signup and view all the answers

    What is the result of the combination of pathophysiologic factors left untreated?

    <p>Increased risk for chronic disease and early all-cause mortality</p> Signup and view all the answers

    What is the role of abnormal fat distribution and partitioning in the metabolic syndrome?

    <p>It is a pathophysiologic link between obesity and hormonal and metabolic derangements</p> Signup and view all the answers

    What is the effect of accumulation of fatty acids in non-adipose tissue depots on skeletal muscle?

    <p>It is associated with skeletal muscle insulin resistance</p> Signup and view all the answers

    What is the characteristic of mitochondria in obese, sedentary, and insulin-resistant individuals?

    <p>Smaller and fewer</p> Signup and view all the answers

    What is the consequence of diminished mitochondrial density and function?

    <p>Decreased or incomplete lipid oxidation and subsequent accumulation of lipid metabolites</p> Signup and view all the answers

    What is the effect of sedentary behavior on mitochondrial function?

    <p>It impairs mitochondrial function</p> Signup and view all the answers

    What is the role of adipose tissue in the development of insulin resistance?

    <p>It secretes proinflammatory cytokines that contribute to insulin resistance</p> Signup and view all the answers

    What is the effect of exercise interventions on ATP synthesis and fatty acid oxidation?

    <p>It improves ATP synthesis and fatty acid oxidation</p> Signup and view all the answers

    What is the minimum duration of a daily bout of physical activity?

    <p>10 minutes</p> Signup and view all the answers

    What type of exercise is suitable for individuals with metabolic syndrome?

    <p>Brisk walking, swimming, and cycling</p> Signup and view all the answers

    How often should resistance exercise training be performed?

    <p>2 non-consecutive days per week</p> Signup and view all the answers

    What is the recommended number of exercises for the whole body?

    <p>5-10 exercises</p> Signup and view all the answers

    What is the recommended intensity for resistance exercise?

    <p>Light to moderate intensity</p> Signup and view all the answers

    What is the purpose of ROM and flexibility training?

    <p>To supplement cardiorespiratory and resistance exercise</p> Signup and view all the answers

    What is the effect of diet-induced weight loss on insulin sensitivity?

    <p>It has limited utility for establishing a sustainable, insulin-sensitive phenotype</p> Signup and view all the answers

    What is the effect of cardiorespiratory exercise and resistance exercise on cardiometabolic profile?

    <p>It improves cardiometabolic profile</p> Signup and view all the answers

    What is the association between adiposity and muscle function?

    <p>There is an inverse association between adiposity and muscle function.</p> Signup and view all the answers

    What is the effect of a single bout of cardiorespiratory exercise on whole-body glucose disposal?

    <p>It increases significantly.</p> Signup and view all the answers

    What is the result of chronic adaptation to repeated bouts of exercise?

    <p>Enhanced cardiorespiratory function and global improvements in insulin action.</p> Signup and view all the answers

    What is the effect of cardiorespiratory exercise on blood pressure and lipid profiles?

    <p>It improves them.</p> Signup and view all the answers

    What is the effect of resistance exercise on weight loss?

    <p>It does not promote clinically significant weight loss.</p> Signup and view all the answers

    What is the benefit of combining diet-induced energy restriction and resistance training?

    <p>It prevents loss in muscle tissue.</p> Signup and view all the answers

    What is the benefit of combining aerobic and resistance exercise?

    <p>It is superior to either modality alone.</p> Signup and view all the answers

    What is the benefit of resistance exercise for glycaemic control and insulin sensitivity?

    <p>It is superior to aerobic exercise.</p> Signup and view all the answers

    What is the association between range of motion exercise and cardiometabolic health?

    <p>It has no correlation.</p> Signup and view all the answers

    What is required for the diagnosis of metabolic syndrome?

    <p>The presence of three or more risk factors.</p> Signup and view all the answers

    Why is exercise considered a vital component of diabetes management?

    <p>Because it can improve insulin sensitivity</p> Signup and view all the answers

    What is the benefit of monitoring blood glucose levels before and after exercise?

    <p>To allow for early detection of hypoglycaemia or hyperglycaemia</p> Signup and view all the answers

    What is the effect of exercise performed at an intensity below the threshold for an increase in maximal oxygen uptake?

    <p>It can be beneficial to health in persons with chronic diseases like diabetes</p> Signup and view all the answers

    Why is exercise important for people with type I diabetes?

    <p>Because it is an important part of a healthy lifestyle</p> Signup and view all the answers

    What is the benefit of monitoring blood glucose levels during exercise?

    <p>To identify those who can benefit from monitoring during and after exercise</p> Signup and view all the answers

    What is the benefit of exercising with a frequency and duration that are sufficient?

    <p>It can be beneficial to health in persons with chronic diseases like diabetes</p> Signup and view all the answers

    What is a common symptom of diabetic neuropathy?

    <p>Loss of tendon reflexes</p> Signup and view all the answers

    Why are patients with diabetic neuropathy at high risk for foot trauma?

    <p>Because their feet become insensate, making it difficult to detect injuries</p> Signup and view all the answers

    What is a potential consequence of chronic diabetic neuropathy?

    <p>Increased risk of foot deformities and amputations</p> Signup and view all the answers

    Why is it important for patients with peripheral neuropathy to practice good foot care?

    <p>To detect and prevent foot trauma that can go undetected</p> Signup and view all the answers

    What is a complication of diabetic autonomic neuropathy?

    <p>Abnormal blood pressure response to exercise</p> Signup and view all the answers

    What is a potential consequence of gait changes due to diabetic neuropathy?

    <p>Increased risk of falling due to gait changes</p> Signup and view all the answers

    What is a potential benefit of balance training for patients with diabetic neuropathy?

    <p>Lowered risk of falling due to gait changes</p> Signup and view all the answers

    Why is exercise instruction important for patients with diabetic neuropathy?

    <p>To reduce the risk of foot trauma</p> Signup and view all the answers

    Why is it easier to manage blood sugar levels during exercise in the morning compared to the evening?

    <p>Because blood glucose is utilised within muscle cells to restore glycogen after exercise</p> Signup and view all the answers

    What is a benefit of resistance training for people with diabetes?

    <p>Improving cardiovascular function, insulin sensitivity, strength, and body composition</p> Signup and view all the answers

    What is the purpose of modifying resistance training exercises for people with diabetes?

    <p>To minimize the amount of sustained gripping or isometric contractions</p> Signup and view all the answers

    Why is balance training recommended for people with diabetes?

    <p>To reduce the risk of falls in people with diabetes</p> Signup and view all the answers

    What should be included in a resistance training program for people with diabetes?

    <p>5-10 exercises involving major muscle groups performed with 1-3 sets of 8-15 repetitions</p> Signup and view all the answers

    What should be the progression of intensity, frequency, and duration in a resistance training program?

    <p>Slow and gradual increase in intensity, frequency, and duration</p> Signup and view all the answers

    What is the role of exercise training in managing diabetes?

    <p>To promote blood glucose uptake by the skeletal muscles</p> Signup and view all the answers

    What is a common symptom of diabetes?

    <p>Polyphagia</p> Signup and view all the answers

    What is a potential indicator of complications in patients with diabetes?

    <p>Loss of sensation or reflexes in the lower extremities</p> Signup and view all the answers

    Why is it important to evaluate patients with diabetes during an annual physical examination?

    <p>To evaluate for potential indicators of complications</p> Signup and view all the answers

    What is a factor to consider when determining the necessity of obtaining a medical clearance for exercise?

    <p>Body weight and BMI</p> Signup and view all the answers

    What is a recommended question to ask patients before each exercise training session?

    <p>What is your starting blood glucose level?</p> Signup and view all the answers

    What is the purpose of inquiring about the patient's medication use and timing before exercise?

    <p>To prevent acute complications</p> Signup and view all the answers

    What is a characteristic of those with type II diabetes?

    <p>They may remain asymptomatic</p> Signup and view all the answers

    What is a potential complication of diabetes?

    <p>Foot sores or ulcers that heal poorly</p> Signup and view all the answers

    What is the effect of acute bouts of exercise on blood glucose levels in those with type II diabetes?

    <p>A reduction in blood glucose levels</p> Signup and view all the answers

    Why is exercise important for people with type I diabetes?

    <p>To reduce the risk of hypoglycemia</p> Signup and view all the answers

    What is the benefit of regular, long-term exercise for those with diabetes?

    <p>All of the above</p> Signup and view all the answers

    What is the effect of high-intensity, short-term exercise on blood glucose levels in those with type I diabetes?

    <p>An increase in blood glucose levels</p> Signup and view all the answers

    What is the recommended approach to exercise for individuals with diabetes?

    <p>Mild to moderate, regular exercise</p> Signup and view all the answers

    Why is it important to monitor blood glucose levels before and after exercise?

    <p>To prevent hypoglycemia</p> Signup and view all the answers

    What is the estimated prevalence of polycystic ovarian syndrome (PCOS) in women of reproductive age?

    <p>4-20%</p> Signup and view all the answers

    Which of the following is a common clinical feature of PCOS?

    <p>Hirsutism</p> Signup and view all the answers

    Elevated levels of which hormone are often seen in PCOS?

    <p>Luteinising hormone</p> Signup and view all the answers

    What is a common metabolic feature of PCOS?

    <p>Insulin resistance</p> Signup and view all the answers

    What is a common menstrual disturbance associated with PCOS?

    <p>Oligomenorrhea</p> Signup and view all the answers

    What is a common complication of PCOS?

    <p>Recurrent miscarriages</p> Signup and view all the answers

    What percentage of women with PCOS have normal menses?

    <p>30%</p> Signup and view all the answers

    What is the incidence of spontaneous abortion in women with PCOS?

    <p>42-73%</p> Signup and view all the answers

    What is a common comorbidity of PCOS?

    <p>Hypertension</p> Signup and view all the answers

    What is required for the diagnosis of PCOS?

    <p>At least two of the following characteristics</p> Signup and view all the answers

    What is strongly implicated in the aetiology of PCOS?

    <p>Insulin resistance</p> Signup and view all the answers

    What is a mental health disorder that occurs more frequently in women with PCOS?

    <p>All of the above</p> Signup and view all the answers

    What percentage of women with oligomenorrhea have PCOS?

    <p>85-90%</p> Signup and view all the answers

    What is the percentage of women with PCOS who experience infertility?

    <p>30-40%</p> Signup and view all the answers

    What is believed to contribute to the heterogeneity of PCOS?

    <p>Multiple pathophysiological mechanisms</p> Signup and view all the answers

    What is a significant economic burden of PCOS in the USA?

    <p>$4.4 billion annually</p> Signup and view all the answers

    What is a primary focus of pharmaceutical treatment for PCOS?

    <p>Addressing reproductive dysfunction and insulin resistance</p> Signup and view all the answers

    What is a potential consequence of untreated PCOS?

    <p>Increased risk of endometrial cancer and cardiovascular disease</p> Signup and view all the answers

    What is a common feature of PCOS?

    <p>A familial pattern in some cases</p> Signup and view all the answers

    What is used to treat menstrual irregularity, hirsutism, and acne in PCOS?

    <p>Oral contraceptives</p> Signup and view all the answers

    What is the primary goal of pharmacological intervention in PCOS?

    <p>To induce ovulation</p> Signup and view all the answers

    What is the role of metformin in PCOS?

    <p>To reduce insulin resistance</p> Signup and view all the answers

    What is the effect of exercise intervention on follicle-stimulating hormone in women with PCOS?

    <p>Increase</p> Signup and view all the answers

    What is the recommended duration of aerobic activity per week for women with PCOS?

    <p>At least 90 minutes</p> Signup and view all the answers

    What is the effect of exercise intervention on total testosterone in women with PCOS?

    <p>Decrease</p> Signup and view all the answers

    What is the effect of exercise intervention on insulin resistance in women with PCOS?

    <p>Decrease</p> Signup and view all the answers

    What is the effect of exercise intervention on blood lipids in women with PCOS?

    <p>Variable</p> Signup and view all the answers

    What is the effect of exercise intervention on reproductive function in women with PCOS?

    <p>Increase</p> Signup and view all the answers

    What is the primary mechanism underlying the improvement in reproductive function with exercise in women with PCOS?

    <p>Improved insulin sensitivity</p> Signup and view all the answers

    What is the recommended approach to exercise prescription for women with PCOS?

    <p>Individualized to the patient based on presentation and clinical features/comorbidities</p> Signup and view all the answers

    What is an effective way to improve upper airway patency during sleep?

    <p>Using a positioning device to maintain a non-supine position</p> Signup and view all the answers

    Which of the following is a potential benefit of successful dietary weight loss in obese patients with OSA?

    <p>Improved AHI</p> Signup and view all the answers

    What is the purpose of positional therapy in patients with OSA?

    <p>To keep patients in a non-supine position</p> Signup and view all the answers

    What is a potential benefit of custom-made oral appliances in patients with OSA?

    <p>Enlarged upper airway and/or decreased upper airway collapsibility</p> Signup and view all the answers

    Why is sleep position important in patients with OSA?

    <p>Because it can affect upper airway size and patency</p> Signup and view all the answers

    What is a lifestyle modification that can improve patient comfort and adherence in patients with OSA?

    <p>Engaging in regular exercise</p> Signup and view all the answers

    What is the primary function of Mandibular Repositioning Appliances (MRAs)?

    <p>To hold the upper and lower teeth in an advanced position</p> Signup and view all the answers

    What is the primary indication for surgical treatment of OSA?

    <p>Mild OSA with surgically correctible anatomy</p> Signup and view all the answers

    What is the remission rate for OSA two years after bariatric surgery?

    <p>40%</p> Signup and view all the answers

    What is the primary role of Tongue Retaining Devices (TRDs)?

    <p>To hold the tongue in a forward position</p> Signup and view all the answers

    What is the primary indication for oral appliances in OSA treatment?

    <p>Mild to moderate OSA who prefer oral appliances to CPAP</p> Signup and view all the answers

    What is the primary surgical approach for OSA treatment?

    <p>Reconstructive or by-pass procedures</p> Signup and view all the answers

    What is the primary benefit of bariatric surgery for OSA treatment?

    <p>Major weight loss and remission of OSA</p> Signup and view all the answers

    What is the primary pharmacological approach for OSA treatment?

    <p>Pharmacotherapy for hypothyroidism or acromegaly</p> Signup and view all the answers

    What is the main reason for exercise reducing AHI in mild or severe OSA?

    <p>Reduction in adipose tissue in the pharyngeal airway</p> Signup and view all the answers

    What is the approximate reduction in OSA severity achieved through exercise?

    <p>25-30%</p> Signup and view all the answers

    What is the effect of exercise on Epworth Sleepiness Scale scores in patients with OSA?

    <p>Reduction</p> Signup and view all the answers

    What is the ideal adjunct therapy for OSA, according to the text?

    <p>Exercise training</p> Signup and view all the answers

    What is the relationship between exercise and AHI reduction, independent of BMI?

    <p>Inverse relationship</p> Signup and view all the answers

    What is not recommended as a primary treatment for OSA?

    <p>Oxygen supplementation</p> Signup and view all the answers

    What is the effect of exercise on sleep efficiency in patients with OSA?

    <p>Increase</p> Signup and view all the answers

    What is the significance of the 25-30% reduction in OSA severity achieved through exercise?

    <p>Equivalent to a 10% dietary-induced body mass reduction</p> Signup and view all the answers

    What is recommended for the treatment of residual excessive daytime sleepiness in OSA patients?

    <p>Modafinil</p> Signup and view all the answers

    What is the effect of exercise on OSA?

    <p>Decreases AHI</p> Signup and view all the answers

    What is the benefit of combining exercise with other therapies for OSA?

    <p>Additive effect</p> Signup and view all the answers

    What is the impact of exercise on body mass or BMI in OSA?

    <p>Has no impact on BMI</p> Signup and view all the answers

    What is the potential benefit of exercise in OSA patients?

    <p>Reduces the severity of OSA</p> Signup and view all the answers

    What is the current understanding of how exercise reduces OSA symptoms?

    <p>Through a complex interplay of factors</p> Signup and view all the answers

    What is the limitation of the available RCTs on exercise in OSA?

    <p>There is marked heterogeneity of the exercise protocols used</p> Signup and view all the answers

    What is the potential benefit of combining exercise with other treatments for OSA?

    <p>It may improve comorbidities such as diabetes, CVD, hypertension, and obesity</p> Signup and view all the answers

    Which of the following physical examination features may suggest the presence of OSA?

    <p>Increased neck circumference</p> Signup and view all the answers

    What is the minimum number of physiologic signals required for polysomnography?

    <p>6</p> Signup and view all the answers

    What is the primary purpose of portable monitors in the diagnosis of OSA?

    <p>To diagnose OSA in patients with high pre-test probability</p> Signup and view all the answers

    What is the severity of OSA based on?

    <p>The number of apnoea or hypopnoea events per hour of sleep</p> Signup and view all the answers

    What is the recommended first-line treatment for severe OSA?

    <p>Continuous positive airway pressure (CPAP)</p> Signup and view all the answers

    What is the purpose of pressure relief in PAP therapy?

    <p>To decrease the pressure during expiration</p> Signup and view all the answers

    Which of the following is a complication of untreated OSA?

    <p>All of the above</p> Signup and view all the answers

    What is the AHI range for mild OSA?

    <p>AHI ≥ 5 and &lt; 15</p> Signup and view all the answers

    What is the role of PAP in OSA treatment?

    <p>To provide pneumatic splinting of the upper airway</p> Signup and view all the answers

    What is the benefit of CPAP therapy in OSA treatment?

    <p>All of the above</p> Signup and view all the answers

    Study Notes

    Insulin Resistance and the Metabolic Syndrome

    • The clustering of multiple risk components within the metabolic syndrome is thought to occur as a result of obesity (specifically abdominal obesity) and insulin resistance
    • Insulin resistance is a hallmark of chronic health risk, but not all obese or insulin-resistant individuals develop the metabolic syndrome
    • Gradual decreases in cardiometabolic health can occur long before an individual reaches obesity or is diagnosed as insulin resistant

    Insulin Signalling and Glucose Uptake

    • In healthy, insulin-sensitive individuals, glucose stimulates the release of insulin from pancreatic beta cells, which reduces plasma glucose concentration through suppression of hepatic glycogenolysis and gluconeogenesis and simultaneous glucose uptake, utilization, and storage by the liver, muscle, and adipose tissue
    • Conversely, under conditions of insulin resistance, there is a chronic failure of insulin to maintain glucose homeostasis

    Obesity and Adiposity Distribution Abnormalities

    • Obesity is an independent risk factor for insulin resistance, hyperglycaemia, hypercholesterolaemia, and hypertension
    • Abnormal fat distribution and partitioning may be the pathophysiologic link between obesity and the metabolic syndrome
    • Accumulation of fatty acids in non-adipose tissue depots is associated with skeletal muscle insulin resistance

    Mitochondrial Dysfunction

    • Mitochondrial dysfunction is implicated in the aetiology of insulin resistance, metabolic syndrome, and diabetes
    • Obese, sedentary, and insulin-resistant individuals have smaller and fewer mitochondria with impaired function
    • Diminished mitochondrial density and function may lead to or coincide with decreased or incomplete lipid oxidation and subsequent accumulation of lipid metabolites, impaired insulin signalling, metabolic inflexibility, and oxidative stress

    Proinflammatory and Prothrombotic Characteristics

    • Adipose tissue is a dynamic organ that secretes adipocyte-derived hormones and cytokines, contributing to insulin resistance
    • Ectopic adiposity is known to play a role in secreting proinflammatory cytokines (e.g., TNF-α and IL-6) and adipocytokines (e.g., leptin, resistin, and adiponectin)
    • Elevated levels of hs-CRP are associated with ASCVD and inversely associated with vigorous physical activity

    Exercise Prescription Summary

    • Cardiorespiratory exercise and resistance exercise are effective for improving cardiometabolic health, independent of weight loss
    • Exercise prescription should include gradual progression in duration and intensity, with a minimum of 2-3 non-consecutive days per week
    • Range of motion exercise may be included as an adjunct modality to supplement cardiorespiratory and resistance exercise

    Exercise Training

    • Exercise training, particularly cardiorespiratory exercise, is effective for improving metabolic disturbances, independent of weight loss
    • Resistance exercise is effective for enhancing muscle function, insulin sensitivity, and fatty acid oxidation, and for decreasing visceral adiposity
    • Combining diet-induced energy restriction and resistance training has been shown to prevent loss in muscle tissue

    Monitoring and Recording Blood Glucose Levels

    • Monitoring blood glucose levels before and after exercise can allow for early detection of hypoglycaemia or hyperglycaemia, and help determine appropriate pre-exercise blood glucose levels to lower the risk of these conditions.
    • Monitoring can also identify those who can benefit from monitoring during and after exercise, provide information for modifying the exercise prescription, and allow for better adjustment of diabetes regimens to manage all activities.
    • Monitoring can motivate patients to remain more active to better manage their diabetes.

    Exercise and Diabetes Management

    • Exercise is a vital component of diabetes management and is considered a method of treatment for type II diabetes because it can improve insulin resistance.
    • Although exercise alone is not considered a method of treating type I diabetes, it is still an important part of a healthy lifestyle for people in this group.
    • Exercise performed at an intensity below the threshold for an increase in maximal oxygen uptake can be beneficial to health in persons with chronic diseases like diabetes.

    Complications of Diabetes

    • Chronic complications of diabetes include peripheral neuropathy, which can cause sensory symptoms, muscle weakness, and foot deformities, placing patients at high risk for foot trauma and injury.
    • Peripheral neuropathy can also change gait and balance, increasing the risk of falling, but balance training may help lower this risk.
    • Diabetic autonomic neuropathy can occur in any system of the body, affecting the ability to perform exercise, and may be manifested by high resting heart rate, attenuated exercise heart rate response, and abnormal blood pressure.

    Goal Times and Glycaemic Recommendations

    • Goal times for blood glucose levels are critical for people with diabetes.
    • Glycaemic recommendations for non-pregnant adults with diabetes include maintaining blood glucose levels as close to normal as possible.

    Signs and Symptoms of Diabetes

    • Classic symptoms of diabetes include polydipsia, polyuria, and polyphagia.
    • Other symptoms of diabetes include unexplained weight loss, infections and cuts that are slow to heal, blurry vision, and fatigue.
    • Many people with diabetes may remain asymptomatic, and about one-fourth of those with diabetes do not know they have the disease.

    History and Physical Examination

    • Patients with diabetes should have an annual physical examination to evaluate for potential indicators of complications, including elevated resting heart rate, loss of sensation or reflexes, and foot sores or ulcers.
    • Exercise testing may be appropriate before beginning an exercise program.
    • Prior to each exercise training session, healthcare professionals should inquire about the patient's starting blood glucose level, timing and amount of most recent food intake, and medication use and timing.

    Resistance Exercise

    • Resistance training programs can improve cardiovascular function, insulin sensitivity, strength, and body composition in people with diabetes.
    • Resistance training exercises should be done 2-3 days per week on non-consecutive days, and progression of intensity, frequency, and duration should occur slowly.

    Range of Motion and Balance Exercise

    • Range of motion exercises can be included as part of an exercise program, but should not be substituted for aerobic or resistance exercise.
    • Balance training is recommended for all individuals over the age of 40, as it reduces the risk of falls in people with diabetes, even with peripheral neuropathy.

    Exercise Prescription Summary

    • Exercise training considerations for diabetes include the importance of promoting blood glucose uptake by the skeletal muscles.
    • Benefits for people with diabetes are seen with both acute and chronic cardiorespiratory and resistance exercise training.
    • Acute bouts of exercise can improve blood glucose, particularly in those with type II diabetes.

    Polycystic Ovarian Syndrome (PCOS)

    • PCOS is an endocrinopathy of uncertain aetiology, affecting 4-20% of women of reproductive age.

    Clinical Features

    • PCOS is characterized by:
      • Menstrual abnormalities (oligomennorhea or amenorrhea)
      • Hirsutism
      • Acne
      • Alopecia
      • Anovulatory infertility
      • Recurrent miscarriages

    Endocrine Features

    • PCOS is associated with:
      • Elevated androgens
      • Luteinising hormone
      • Oestrogen
      • Prolactin

    Metabolic Features

    • PCOS often includes:
      • Insulin resistance
      • Obesity
      • Lipid abnormalities
      • Increased risk for impaired glucose tolerance and T2DM

    Prevalence of Common Features

    • Menstrual disturbances:
      • 30% of women with PCOS have normal menses
      • 85-90% of women with oligomenorrhea have PCOS
      • 30-40% of women with amenorrhea have PCOS
    • Infertility affects 40% of women with PCOS
    • 90-95% of anovulatory women presenting to infertility clinics have PCOS
    • Spontaneous abortion occurs in 42-73% of women with PCOS

    Risk Factors

    • Risk factors for PCOS in adults include:
      • T1DM
      • T2DM
      • GDM

    Common Comorbidities

    • Insulin resistance affects 50-70% of women with PCOS, leading to:
      • Metabolic syndrome
      • Hypertension
      • Dyslipidaemia
      • Glucose intolerance
      • Diabetes
    • Women with PCOS are more likely to have increased coronary artery calcium scores
    • Mental health disorders, including:
      • Depression
      • Anxiety
      • Bipolar disorder
      • Binge eating disorder

    Diagnostic Criteria

    • Diagnosis of PCOS requires at least two of the following characteristics:
      • Clinical or biochemical hyperandrogenism
      • Anovulatory menstrual dysfunction
      • Polycystic ovaries on ultrasound
    • Insulin resistance is strongly implicated in the aetiology of PCOS, although not included in the diagnostic criteria

    Pathophysiology

    • The pathophysiology of PCOS is complex and multifactorial, involving:
      • Unique defect in insulin action and secretion
      • Primary neuroendocrine defect
      • Defect of androgen synthesis
      • Alteration in cortisol metabolism
    • A familial pattern in some cases suggests a genetic component, but the candidate genes are yet to be identified

    Economic Burden

    • PCOS costs the USA healthcare system $4.4 billion annually, with:
      • 40% attributed to treating reproductive dysfunction
      • 40% attributed to PCOS-related diabetes

    Pharmaceutical Intervention

    • Pharmaceutical treatment for PCOS focuses on addressing reproductive dysfunction and insulin resistance, using:
      • Oral contraceptives
      • Spironolactone
      • Finasteride
      • Fertility treatments, including ovulation induction agents and assisted reproductive technology
      • Metformin

    Exercise Intervention

    • There are currently no evidence-based exercise guidelines for the treatment of PCOS, and exercise prescription should be individualized to the patient based on presentation and clinical features/comorbidities
    • Exercise intervention in women with PCOS has been shown to:
      • Increase follicle-stimulating hormone
      • Increase sex hormone-binding globulin
      • Decrease total testosterone
      • Decrease androstenedione
    • The most consistent improvements were demonstrated in:
      • Weight loss
      • Insulin resistance
      • Reproductive function
    • Women with PCOS should be advised to engage in at least 90 minutes of aerobic activity per week at a moderate intensity to achieve improved reproductive and cardiometabolic outcomes.

    Obstructive Sleep Apnoea (OSA)

    • OSA is a sleep disorder where a person's breathing is interrupted during sleep
    • OSA is associated with various conditions, including:
      • Hypertension
      • CVA
      • MI
      • Cor pulmonale
      • Motor vehicle accidents

    Physical Examination

    • The physical examination can suggest increased risk of OSA and should include evaluation of:
      • Respiratory system
      • Cardiovascular system
      • Neurological system
    • Particular attention should be paid to:
      • Obesity
      • Upper airway narrowing
      • Other disorders that can contribute to OSA development or consequences

    Physical Examination Features

    • Features to be evaluated that may suggest OSA presence:
      • Increased neck circumference (> 17 inches in men, > 16 inches in women)
      • BMI ≥ 30
      • Modified Mallampati score of 3 or 4
      • Retrognathia
      • Lateral peritonsillar narrowing
      • Macroglossia
      • Tonsillar hypertrophy
      • Elongated or enlarged uvula
      • High arched or narrow hard palate
      • Nasal abnormalities

    Objective Testing

    • Following history and physical examination, patients can be stratified according to OSA disease risk
    • High-risk patients should have the diagnosis confirmed and severity determined with objective testing
    • Severity of OSA must be established to make an appropriate treatment decision
    • Objective testing methods:
      • In-laboratory polysomnography
      • Home testing with portable monitors

    Polysomnography

    • Polysomnography requires the following physiologic signals:
      • Electroencephalogram (EEG)
      • Electrooculogram (EOG)
      • Chin electromyogram
      • Airflow
      • Oxygen saturation
      • Respiratory effort
      • Electrocardiogram (ECG) or heart rate
    • Additional recommended parameters:
      • Body position
      • Leg EMG derivations

    Portable Monitors

    • Portable monitors should, at a minimum, record:
      • Airflow
      • Respiratory effort
      • Blood oxygenation
    • Portable monitors may be used in the unattended setting as an alternative to polysomnography for the diagnosis of OSA in patients with a high pre-test probability of moderate to severe OSA and no comorbid sleep disorder or major comorbid medical disorder

    Categorisation of Severity

    • The measure of severity of OSA is based on the number of apnoea or hypopnoea events per hour of sleep, represented by the Apnoea Hypopnoea Index (AHI)
    • Parameters for OSA:
      • Normal: AHI < 5
      • Mild: AHI ≥ 5 and < 15
      • Moderate: AHI ≥ 15 and < 30
      • Severe: AHI ≥ 30

    Treatment - PAP

    • The American Academy of Sleep Medicine recommends the use of continuous positive airway pressure (CPAP) or oral appliances for treating mild to moderate OSA
    • CPAP is recommended as the first-line, and oral appliances as second-line, treatments for severe OSA
    • CPAP provides pneumatic splinting of the upper airway and is effective in reducing the AHI
    • PAP may be delivered in continuous, bilevel, or autotitrating modes, with additional options for pressure relief and BPAP/APAP modes

    Treatment - Behavioural Strategies

    • Behavioural treatment options:
      • Weight loss
      • Exercise
      • Positional therapy
      • Avoidance of alcohol or sedatives before bedtime
    • Successful dietary weight loss may improve the AHI in obese patients with OSA
    • Sleep position can affect airway size and patency, with a decrease in the area of the upper airway, particularly in the lateral dimension, while in the supine position
    • Positional therapy consists of a method that keeps the patient in a non-supine position, using a positioning device (e.g., alarm, pillow, backpack, or tennis ball)

    Treatment - Oral Appliances

    • Custom-made oral appliances may improve upper airway patency during sleep by enlarging the upper airway and/or by decreasing upper airway collapsibility
    • Mandibular repositioning appliances (MRA) cover the upper and lower teeth and hold the mandible in an advanced position with respect to the resting position
    • Tongue retaining devices (TRD) hold only the tongue in a forward position with respect to the resting position, without mandibular repositioning
    • Oral appliances are indicated for use in patients with mild to moderate OSA who prefer oral appliances to CPAP, or who do not respond to CPAP, are not appropriate candidates for CPAP, or who fail CPAP or behavioural measures

    Treatment - Surgical

    • Surgical therapy includes a variety of upper airway reconstructive or by-pass procedures, often site-directed and/or staged
    • Evaluation for primary surgical treatment can be considered in patients with mild OSA who have severe obstructing anatomy that is surgically correctable
    • Surgical procedures may be considered as a secondary treatment for OSA when the outcome of PAP therapy is inadequate, such as when the patient is intolerant of PAP, or PAP therapy is unable to eliminate OSA

    Adjunctive Therapies - Bariatric Surgery

    • Bariatric surgery is an effective means to achieve major weight loss and is indicated in individuals with a BMI ≥ 40 or those with a BMI ≥ 35 with important comorbidities and in whom dietary attempts at weight control have been ineffective
    • The remission rate for OSA two years after bariatric surgery, related to the amount of weight lost, is 40%

    Adjunctive Therapies - Pharmacotherapy and Supplemental Oxygen

    • There are no widely effective pharmacotherapies for OSA with the important exceptions of individuals with hypothyroidism or acromegaly
    • Treatment of those underlying medical conditions can improve the AHI
    • Oxygen supplementation is not recommended as a primary treatment for OSA
    • Supplemental oxygen alone may reduce nocturnal hypoxaemia, but may also prolong apnoeas and may potentially worsen hypercapnia in patients with comorbid respiratory disease
    • Modafinil is recommended for the treatment of residual excessive daytime sleepiness in OSA patients who have sleepiness despite effective PAP treatment and who are lacking any other identifiable cause of their sleepiness

    A Role for Exercise?

    • Exercise has been shown to reduce the severity of OSA, independent of BMI
    • Exercise has been documented to achieve a 25-30% reduction in OSA severity
    • A dietary-induced body mass reduction of 10% is required to achieve this same level of OSA severity improvement
    • Even modest improvements in OSA severity have been associated with significantly reduced risk of adverse health outcomes

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    Learn about the risk factors that contribute to the metabolic syndrome, including sedentary behavior, atherogenic diet, genetic predisposition, and more. Understand the role of obesity and insulin resistance in developing the syndrome.

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