EHR522 weeks 5-9
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Questions and Answers

What is the effect of acute exercise on blood glucose levels in those with type I diabetes and lean patients with type II diabetes?

  • Variable and unpredictable (correct)
  • Always a reduction in BGLs
  • Always an increase in BGLs
  • No effect

    • Regular, long-term exercise provides no benefits for those with diabetes.

    False

    What is the response of blood glucose to exercise related to?

    pre-exercise blood glucose levels, duration and intensity of exercise

    A reduction in BGLs is sustained into the post-exercise period following ______________________ exercise.

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

    Match the following exercise types with their benefits for persons with diabetes:

    <p>Cardiorespiratory exercise = Improves blood glucose levels Resistance exercise = Increases muscle glucose use Acute exercise = Reduces hepatic glucose production Chronic exercise = Provides long-term benefits</p> Signup and view all the answers

    What is one of the benefits of exercise training on glucose control?

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

    Visceral or abdominal body fat is positively associated with insulin sensitivity.

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

    What is the name of the protein that is involved in glucose transport in muscle?

    <p>GLUT4</p> Signup and view all the answers

    Weight loss is often a therapeutic goal for those with type II diabetes because most are ______________ or obese.

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

    Match the following benefits of exercise training with their corresponding descriptions:

    <p>Metabolic control = Improvements in glucose control and insulin resistance Hypertension = Lowering of blood pressure Lipids = Improvements in cholesterol levels Body composition = Changes in body fat and muscle mass</p> Signup and view all the answers

    What is a common feature of type II diabetes?

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

    Ketoacidosis frequently occurs in type II diabetes.

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

    What is the risk of developing type II diabetes among offspring with two parents who have type II diabetes?

    <p>6-fold higher</p> Signup and view all the answers

    Gestational diabetes is usually diagnosed with _______________________ performed routinely at 24 – 28 weeks of pregnancy.

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

    Match the following types of diabetes with their characteristics:

    <p>Type II diabetes = Insulin resistance and defective insulin secretion Gestational diabetes = Diabetes diagnosed in the second or third trimester of pregnancy Other specific types of diabetes = Caused by certain diseases, injuries, infections, medications or genetic syndromes</p> Signup and view all the answers

    What is a complication of high blood glucose levels?

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

    Frequent high blood glucose levels can increase the risk of chronic complications.

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

    What is the best treatment for someone with frequently elevated blood glucose levels with ineffective management?

    <p>Drinking plenty of non-carbohydrate-containing beverages, regular self-monitoring of blood glucose, and, when instructed by a healthcare professional, an increase in diabetes medications.</p> Signup and view all the answers

    Diabetic ketoacidosis occurs in patients whose diabetes is in poor control and in whom the amount of effective ______ is very low or absent.

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

    Match the acute complications of diabetes with their descriptions:

    <p>Hyperglycaemia = Blood glucose levels are too high Hypoglycaemia = Blood glucose levels are too low</p> Signup and view all the answers

    What is the effect of low to moderate exercise on blood glucose levels in individuals with type II diabetes who are managed by diet and exercise alone?

    <p>Reduction in blood glucose level</p> Signup and view all the answers

    In poorly controlled diabetes, insulin levels are often too high, resulting in a decrease in counter-regulatory hormones during exercise.

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

    What is the primary reason for monitoring blood glucose levels after an exercise session in individuals with diabetes?

    <p>To determine the patient's response to exercise.</p> Signup and view all the answers

    In the hours following exercise, patients with diabetes are more likely to experience _______________________ (usually < 3.6 mmol/L).

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

    Match the following types of exercise with their potential effect on blood glucose levels:

    <p>High-intensity exercise = Increase in blood glucose level Low to moderate exercise = Reduction in blood glucose level Vigorous exercise = Increase in blood glucose level Post-exercise replacement of muscle glycogen = Decrease in blood glucose level</p> Signup and view all the answers

    What is one of the proposed theories to explain the pathogenesis of PCOS?

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

    The candidate genes responsible for PCOS have been identified.

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

    What is the estimated annual cost of PCOS to the USA healthcare system?

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

    Oral contraceptives are used to treat menstrual irregularity, hirsutism, and ______________________.

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

    Match the following PCOS complications with their descriptions:

    <p>Endometrial cancer = Cancer type associated with PCOS Obesity = Condition often linked to PCOS Cardiovascular disease = Disease that can be linked to PCOS</p> Signup and view all the answers

    PCOS primarily affects reproductive function.

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

    What is the primary goal of pharmacological intervention in PCOS?

    <p>To treat symptoms of androgen excess</p> Signup and view all the answers

    Exercise intervention in PCOS has been shown to decrease sex hormone-binding globulin.

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

    What is the recommended duration of aerobic activity per week to achieve improved reproductive and cardiometabolic outcomes in PCOS?

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

    Insulin resistance in PCOS is unique, being intrinsically present in the majority of lean PCOS women and further exacerbated by extrinsic ___________-related insulin resistance.

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

    Match the following benefits of exercise in PCOS with their descriptions:

    <p>Increased follicle-stimulating hormone = Improved reproductive function Decreased androstenedione = Improved insulin resistance Decreased total testosterone = Improved cardiovascular risk factors</p> Signup and view all the answers

    The evidence suggests that exercise interventions in PCOS can reduce blood lipids.

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

    What is the recommended approach to managing PCOS?

    <p>Exercise and dietary modification as first-line therapy</p> Signup and view all the answers

    What is the estimated prevalence of PCOS in women of reproductive age?

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

    PCOS is a metabolic disorder with a clear aetiology.

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

    List three clinical features of PCOS.

    <p>Menstrual abnormalities, Hirsutism, Acne</p> Signup and view all the answers

    PCOS is often associated with _______________________ resistance.

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

    Match the following features of PCOS with their categories:

    <p>Menstrual abnormalities = Clinical Elevated androgens = Endocrine Insulin resistance = Metabolic</p> Signup and view all the answers

    Recurrent miscarriages are a common feature of PCOS.

    <p>True</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

    PCOS is primarily a reproductive disorder.

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

    What is the estimated percentage of women with PCOS who have insulin resistance?

    <p>50-70%</p> Signup and view all the answers

    Approximately ______% of anovulatory women presenting to infertility clinics have PCOS.

    <p>90-95%</p> Signup and view all the answers

    Match the following comorbidities with PCOS:

    <p>Metabolic syndrome = Comorbidity of PCOS Hypertension = Comorbidity of PCOS Bipolar disorder = Comorbidity of PCOS Asthma = Not a comorbidity of PCOS</p> Signup and view all the answers

    The polycystic ovary morphology is essential for the diagnosis of PCOS.

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

    What is the purpose of positional therapy in treating OSA?

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

    Custom-made oral appliances can improve upper airway patency during sleep.

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

    What is the benefit of successful dietary weight loss in obese patients with OSA?

    <p>Improvement in the AHI</p> Signup and view all the answers

    Avoidance of _______________________ before bedtime is a behavioural treatment option for OSA.

    <p>alcohol or sedatives</p> Signup and view all the answers

    Match the following behavioural treatment options with their descriptions:

    <p>Weight loss = Improves airway patency and reduces OSA severity Exercise = Improves overall health and sleep quality Positional therapy = Keeps the patient in a non-supine position Avoidance of alcohol or sedatives = Improves sleep quality and reduces OSA severity</p> Signup and view all the answers

    What is the effect of supplemental oxygen alone on nocturnal hypoxaemia in patients with comorbid respiratory disease?

    <p>Reduces nocturnal hypoxaemia but may worsen hypercapnia</p> Signup and view all the answers

    Modafinil is recommended for the treatment of residual excessive daytime sleepiness in OSA patients who have sleepiness despite effective PAP treatment.

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

    What are the effects of exercise on OSA?

    <p>Decreases AHI, reduces Epworth Sleepiness Scale, minimal or no reduction in BMI</p> Signup and view all the answers

    Exercise has been shown to reduce the severity of disorders and/or diseases associated with OSA, including ______________.

    <p>diabetes, CVD, hypertension, obesity</p> Signup and view all the answers

    Match the following with their effects on OSA:

    <p>Treatment of underlying medical conditions = Improves AHI Oxygen supplementation = May reduce nocturnal hypoxaemia but may worsen hypercapnia Exercise = Decreases AHI, reduces Epworth Sleepiness Scale, minimal or no reduction in BMI Modafinil = Reduces residual excessive daytime sleepiness</p> Signup and view all the answers

    What is the purpose of mandibular repositioning appliances (MRA) in treating OSA?

    <p>To hold the mandible in an advanced position with respect to the resting position</p> Signup and view all the answers

    Surgical therapy is the first line of treatment for OSA.

    <p>False</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

    Oral appliances are indicated for use in patients with _______ OSA who prefer oral appliances to CPAP.

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

    Match the following treatments with their corresponding descriptions:

    <p>Mandibular repositioning appliances (MRA) = Hold the mandible in an advanced position with respect to the resting position Tongue retaining devices (TRD) = Hold the tongue in a forward position with respect to the resting position Surgical therapy = Upper airway reconstructive or by-pass procedures Bariatric surgery = Achieve major weight loss</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

    The exact aetiology of OSA is known.

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

    What is the measure of severity of OSA based on?

    <p>The number of apnoea or hypopnoea events per hour of sleep, represented by the Apnoea Hypopnoea Index (AHI)</p> Signup and view all the answers

    A portable monitor should, at a minimum, record airflow, respiratory effort, and ______________.

    <p>blood oxygenation</p> Signup and view all the answers

    Match the following parameters with their corresponding AHI values for OSA:

    <p>Normal = AHI &lt; 5 Mild = AHI ≥ 5 and &lt; 15 Moderate = AHI ≥ 15 and &lt; 30 Severe = AHI ≥ 30</p> Signup and view all the answers

    What is a possible reason for exercise reducing AHI in mild or severe OSA?

    <p>Exercise leads to weight loss and reduction in BMI</p> Signup and view all the answers

    Exercise has no effect on OSA severity independent of BMI.

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

    What percentage reduction in OSA severity is achieved through exercise?

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

    A dietary induced body mass reduction of _______ is required to achieve a 25-30% reduction in OSA severity.

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

    Match the following benefits of exercise in OSA with their descriptions:

    <p>Reduction in AHI = Exercise leads to a decrease in adipose tissue in the pharyngeal airway Improvement in sleep efficiency = Exercise has a direct effect on sleep quality Reduced risk of adverse health outcomes = Exercise leads to weight loss and reduction in BMI</p> Signup and view all the answers

    What is typically done to insulin dose when initiating treatment with an amylin analogue?

    <p>Reduced by 50%</p> Signup and view all the answers

    Grapefruit directly interacts with statin medications.

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

    What happens to blood medication levels when statins are taken with grapefruit?

    <p>Blood medication levels may rise faster and remain at higher than normal levels.</p> Signup and view all the answers

    Atorvastatin (Lipitor), simvastatin (Zocor), and lovastatin (Mevacor) are affected more than ______________________ when taken with grapefruit.

    <p>fluvastatin (Lescol), pravastatin (Pravachol) or rosuvastatin (Crestor)</p> Signup and view all the answers

    Match the following types of insulin with their characteristics:

    <p>Rapid Acting Insulin = Peaks within 1-3 hours Short Acting Insulin = Peaks within 2-4 hours Intermediate Acting Insulin = Peaks within 4-8 hours Long Acting and Ultra Long Acting Insulin = Peaks after 8 hours</p> Signup and view all the answers

    Why should patients avoid exercise during the peak insulin dose of a rapid acting insulin?

    <p>To avoid exercise-induced hypoglycemia</p> Signup and view all the answers

    All statins are affected equally by grapefruit.

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

    What is the effect of grapefruit on the absorption of statins from the gut to the bloodstream?

    <p>Grapefruit binds to an intestinal enzyme, blocking its action and making the passage of the medication easier.</p> Signup and view all the answers

    Why should grapefruit products be avoided when taking a statin?

    <p>Because it can interact with the medication</p> Signup and view all the answers

    Niacin therapy often results in flushing, skin rashes, and gastrointestinal problems.

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

    What is a severe side effect arising from medication-induced muscle damage?

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

    Pharmaceutical treatment for PCOS focuses primarily on addressing _______________________ dysfunction and insulin resistance.

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

    Match the following side effects of niacin therapy with their descriptions:

    <p>Flushing = A skin rash or redness Gastrointestinal problems = Stomach upset or diarrhea Pruritus = Itching or skin irritation Hypotension = Low blood pressure</p> Signup and view all the answers

    What is the recommended approach to managing PCOS?

    <p>Combination of lifestyle modifications and pharmacological intervention</p> Signup and view all the answers

    PCOS is a metabolic disorder with a clear aetiology.

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

    What is the primary goal of pharmacological intervention in PCOS?

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

    Oral contraceptives are used to treat menstrual irregularity, hirsutism, and _______________________.

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

    What is the primary mechanism of action of biguanides?

    <p>Decrease hepatic glucose production</p> Signup and view all the answers

    DPP-4 inhibitors are used in the treatment of T1DM.

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

    What is the name of the peptide hormone that is co-secreted with insulin from the pancreatic beta cells and is therefore deficient in diabetics?

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

    The sulfonylureas increase insulin production in the _____________.

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

    Match the following oral glucose-lowering medications with their mechanisms of action:

    <p>Metformin = Decrease hepatic glucose production Sulfonylureas = Increase insulin production in the pancreas Thiazolidinediones = Increase glucose uptake, decrease insulin resistance DPP-4 inhibitors = Inhibit degradation of incretins, increase insulin secretion</p> Signup and view all the answers

    What is a common side effect of thiazolidinediones?

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

    GLP-1 receptor agonists are suitable for T1DM.

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

    The amylin analogue pramlintide is indicated for insulin-treated _________________.

    <p>T2DM and T1DM</p> Signup and view all the answers

    Study Notes

    Pathophysiology of Diabetes

    • Insulin resistance in peripheral tissues and defective insulin secretion are common features of diabetes.
    • With insulin resistance, the body cannot effectively use insulin in the muscles or liver, even though sufficient insulin is being produced.

    Type II Diabetes

    • Lifestyle management, including medical nutrition therapy (MNT) and physical activity, are treatment options for type II diabetes.
    • Medication, including oral agents, insulin, or other injectable diabetes medications, may be needed to reach glycaemic targets if lifestyle management is not effective.
    • Bariatric surgery may be added to the treatment plan for those who are obese (BMI > 35) and have unmanageable diabetes or comorbidities.
    • Ketoacidosis rarely occurs in type II diabetes.
    • A genetic influence is present for type II diabetes, with a 3.5-fold higher risk for offspring with one parent with type II diabetes and a 6-fold higher risk for those with two such parents.
    • Obesity contributes significantly to insulin resistance, with 80% of people with type II diabetes being overweight or obese at disease onset.
    • The risk of developing type II diabetes increases with age, lack of physical activity, history of gestational diabetes, and presence of hypertension or dyslipidaemia.

    Gestational Diabetes

    • Gestational diabetes is defined as "diabetes diagnosed in the second or third trimester of pregnancy that is not clearly either type I or type II diabetes."
    • It is usually diagnosed with an oral glucose tolerance test (OGTT) performed at 24-28 weeks of pregnancy.
    • Risk factors for developing gestational diabetes include family history, previous delivery of large birth weight, obesity, and other factors.
    • Although glucose tolerance usually returns to normal after delivery, women who have had gestational diabetes have a greatly increased risk of conversion to type II diabetes over time.
    • They are recommended to have lifelong screening for the development of diabetes or pre-diabetes at least every three years.
    • Structured moderate physical exercise training during pregnancy decreases the risk of gestational diabetes, diminishes maternal weight gain, and is safe for the mother and neonate.

    Other Specific Types of Diabetes

    • In other specific types of diabetes, certain diseases, injuries, infections, medications, or genetic syndromes cause the diabetes.
    • This type may or may not require insulin treatment.

    Complications of Diabetes - Acute Complications

    • The acute complications of diabetes are hyperglycaemia (high blood glucose) and hypoglycaemia (low blood glucose).
    • Each of these acute complications must be quickly identified to ensure proper treatment and reduce the risk of serious consequences.
    • The manifestations of hyperglycaemia include poorly managed blood glucose levels, diabetic ketoacidosis, and hyperosmolar non-ketotic syndrome.
    • High blood glucose levels cause the kidneys to excrete glucose and water, leading to increased urine production and dehydration.
    • Symptoms of hyperglycaemia and dehydration include headache, blurred vision, increased thirst, weakness, and fatigue.
    • The best treatment for anyone with frequently elevated blood glucose levels includes drinking plenty of non-carbohydrate-containing beverages, regular self-monitoring of blood glucose, and, when instructed by a health care professional, increasing diabetes medications.
    • Frequent high blood glucose levels damage target organs or tissues over time, increasing the risk of chronic complications.

    Prevention and Treatment of Abnormal Blood Glucose

    • Those with type II diabetes who are appropriately managed by diet and exercise alone usually experience a reduction in blood glucose level with low to moderate exercise.
    • Timing of exercise after meals can help many patients with type II diabetes reduce post-prandial hyperglycaemia.
    • Blood glucose should be monitored after an exercise session to determine the patient's response to exercise.
    • Patients are more likely to experience hypoglycaemia (usually < 3.6 mmol/L) after exercise than during due to post-exercise replacement of muscle glycogen, which uses blood glucose.
    • Periodic monitoring of blood glucose is necessary in the hours following exercise to determine whether blood glucose is dropping.
    • More frequent monitoring is especially important when initiating exercise.
    • In poorly controlled diabetes, insulin levels are often too low, resulting in an increase in counter-regulatory hormones with exercise, especially when the exercise is vigorous.
    • This can cause an increase in blood glucose level during and after exercise.

    Cardiorespiratory and Resistance Exercise

    • Benefits for persons 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.
    • The response of blood glucose to exercise is related to pre-exercise blood glucose levels as well as to the duration and intensity of exercise.
    • The effect of acute exercise on blood glucose levels in those with type I diabetes and in lean patients with type II diabetes is more variable and unpredictable, but glycaemic benefits are still possible with concomitant dietary management.
    • A rise in blood glucose with exercise can be seen in patients who are extremely insulin deficient (usually type I) and with short-term, high-intensity exercise.
    • Most of the benefits of exercise for those with diabetes of any type come from regular, long-term exercise.
    • These benefits can include improvements in metabolic control, hypertension, lipids, body composition, and weight loss or maintenance, as well as psychological well-being.
    • Both the frequency of aerobic training and the volume of resistance training appear to be important in lowering overall blood glucose levels in type II diabetes.
    • Like acute exercise, exercise training can improve blood glucose.
    • Exercise training (both aerobic and resistance) improves glucose control as measured by HbA1c or glucose tolerance, primarily in those with type II diabetes.
    • Following exercise training, insulin-mediated glucose disposal is improved, and insulin sensitivity of both skeletal muscle and adipose tissue can improve with or without a change in body composition.
    • Exercise may improve insulin sensitivity through several mechanisms, including changes in body composition, muscle mass, fat oxidation, capillary density, and glucose transporters in muscle (GLUT4).

    Polycystic Ovarian Syndrome (PCOS)

    • PCOS is an endocrinopathy of uncertain aetiology, affecting 4-20% of women of reproductive age
    • Features of PCOS can be broadly divided into three categories: clinical, endocrine, and metabolic

    Clinical Features of PCOS

    • Menstrual abnormalities (oligomenorrhea or amenorrhea)
    • Hirsutism
    • Acne
    • Alopecia
    • Anovulatory infertility
    • Recurrent miscarriages

    Endocrine Features of PCOS

    • Elevated androgens
    • Elevated luteinising hormone
    • Elevated oestrogen
    • Elevated prolactin

    Metabolic Features of PCOS

    • Insulin resistance
    • Obesity
    • Lipid abnormalities
    • Increased risk for impaired glucose tolerance and T2DM

    Prevalence of Common Features of PCOS

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

    Risk Factors for PCOS

    • T1DM
    • T2DM
    • GDM

    Common Comorbidities of PCOS

    • Insulin resistance: 50-70% of women with PCOS
    • Metabolic syndrome
    • Hypertension
    • Dyslipidaemia
    • Glucose intolerance
    • Diabetes
    • Mental health disorders: depression, anxiety, bipolar disorder, binge eating disorder

    Diagnostic Criteria for PCOS

    • At least two of the following characteristics in the absence of other causes:
      • Clinical or biochemical hyperandrogenism
      • Anovulatory menstrual dysfunction
      • Polycystic ovaries on ultrasound

    Pathophysiology of PCOS

    • The heterogeneity of PCOS may represent multiple pathophysiological mechanisms
    • Theories of pathogenesis:
      • Unique defect in insulin action and secretion
      • Primary neuroendocrine defect
      • Defect of androgen synthesis
      • Alteration in cortisol metabolism

    Economic Burden of PCOS

    • $4.4 billion annually in the USA healthcare system
    • 40% attributed to treating reproductive dysfunction (infertility and menstrual dysfunction)
    • 40% attributed to PCOS-related diabetes

    Pharmaceutical Intervention for PCOS

    • Focuses primarily on addressing reproductive dysfunction and insulin resistance
    • Oral contraceptives for menstrual irregularity, hirsutism, and acne
    • Spironolactone (aldosterone antagonist) and finasteride (5-alpha reductase inhibitor) for symptoms of androgen excess
    • Fertility treatments: ovulation induction agents (Clomiphene Citrate), exogenous gonadotropins, laparoscopic ovarian drilling, and assisted reproductive technology
    • Metformin for insulin resistance and ovulation induction

    Exercise Intervention for PCOS

    • Individualised exercise prescription based on presentation and clinical features/comorbidities
    • Improvements in:
      • Follicle-stimulating hormone
      • Sex hormone-binding globulin
      • Decreased total testosterone
      • Decreased androstenedione
    • Weight loss: successful in some studies, but not all
    • Insulin resistance: approximately half of available studies demonstrate improvement with exercise intervention
    • Blood lipids: limited studies demonstrate improvements in triglycerides, HDLc, and LDLc with exercise intervention
    • Blood pressure: approximately half of available studies demonstrate reduction in systolic or diastolic blood pressure with exercise intervention
    • Reproductive function: three out of five studies report improvements in menstrual and/or ovulation frequency with exercise intervention

    Obstructive Sleep Apnea (OSA)

    • Associated with conditions such as hypertension, CVA, MI, cor pulmonale, and motor vehicle accidents
    • Physical examination can suggest increased risk and should include evaluation of respiratory, cardiovascular, and neurological systems

    Physical Examination

    • Features to evaluate:
      • Increased neck circumference (> 17 inches in men, > 16 inches in women)
      • BMI ≥ 30
      • Modified Mallampati score of 3 or 4
      • Presence of retrognathia, lateral peritonsillar narrowing, macroglossia, tonsillar hypertrophy, elongated or narrow hard palate, and nasal abnormalities

    Objective Testing

    • Two accepted methods: in-laboratory polysomnography and home testing with portable monitors
    • Portable monitors can diagnose OSA when used as part of a comprehensive sleep evaluation in patients with high pre-test likelihood of moderate to severe OSA
    • Polysomnography requires recording of:
      • Electroencephalogram (EEG)
      • Electrooculogram (EOG)
      • Chin electromyogram
      • Airflow
      • Oxygen saturation
      • Respiratory effort
      • Electrocardiogram (ECG) or heart rate
    • Additional recommended parameters: body position and leg EMG derivations
    • Portable monitors should record:
      • Airflow
      • Respiratory effort
      • Blood oxygenation

    Categorization of Severity

    • 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

    • American Academy of Sleep Medicine recommends 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
    • PAP provides pneumatic splinting of the upper airway and is effective in reducing the AHI
    • Modes of PAP: continuous (CPAP), bilevel (BPAP), autotitrating (APAP), and partial pressure reduction during expiration (pressure relief)

    Treatment - Behavioral Strategies

    • Behavioral 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
    • Positional therapy can improve the AHI by keeping the patient in a non-supine position

    Treatment - Oral Appliances

    • Custom-made oral appliances can improve upper airway patency during sleep by enlarging the upper airway and/or decreasing upper airway collapsibility
    • Types of oral appliances:
      • Mandibular repositioning appliances (MRA)
      • Tongue retaining devices (TRD)

    Treatment - Surgical

    • Surgical therapy includes 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 correctible
    • Surgical procedures may be considered as a secondary treatment for OSA when the outcome of PAP therapy is inadequate

    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
    • Remission rate for OSA two years after bariatric surgery is 40%

    Adjunctive Therapies - Pharmacotherapy and Supplemental Oxygen

    • There are no widely effective pharmacotherapies for OSA, with the exception of individuals with hypothyroidism or acromegaly
    • Oxygen supplementation is not recommended as a primary treatment for OSA
    • 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?

    • Very few RCTs available that analyze the role of exercise in the management of OSA
    • Meta-analysis of limited available studies shows that exercise in OSA:
      • Decreases AHI
      • Reduces Epworth Sleepiness Scale
      • Has minimal or no reduction in BMI
    • Exercise has been shown to reduce the severity of other disorders and/or diseases associated with OSA, including diabetes, CVD, hypertension, and obesity
    • It is not fully understood how exercise reduces OSA symptoms, but research indicates that the impact of exercise on OSA is not related to a reduction in body mass or BMI

    Medications in Metabolic Disease

    Biguanides

    • Metformin is an example of a biguanide medication
    • Decreases hepatic glucose production
    • May also improve insulin resistance in muscles
    • Very low risk of hypoglycemia (possibly after prolonged strenuous exercise)
    • Not used in patients with abnormal creatinine clearance (CHF and CKD)

    Sulfonylureas (1st Generation)

    • Examples include tolbutamide, tolazamide, and chlorpropamide
    • Increase insulin production in the pancreas
    • Carry a significant risk of hypoglycemia
    • Many have a very long half-life and are typically now only used in patients with a well-established history of taking them

    Sulfonylureas (2nd Generation)

    • Examples include glyburide, glipizide, and glimepiride
    • Increase insulin production in the pancreas
    • Carry a risk of hypoglycemia (but less than that of 1st generation sulfonylureas)
    • More predictable results with fewer side effects and more convenient dosing when compared with 1st generation sulfonylureas

    Thiazolidinediones

    • Examples include pioglitazone and rosiglitazone
    • Works via multiple mechanisms
    • Decrease insulin resistance, increasing glucose uptake
    • Redistribution of fat
    • Minor decrease in hepatic glucose output
    • Preserve beta cell function
    • Decrease vascular inflammation
    • No significant risks with exercise, but can cause mild to moderate oedema

    Alpha-Glucosidase Inhibitors

    • Examples include acarbose and miglitol
    • Slow the absorption of starch, disaccharides, and polysaccharides from the GI tract
    • No significant risks with exercise, but can cause gas, bloating, and occasionally diarrhoea

    Dipeptidyl Peptidase 4 (DPP-4) Inhibitors

    • Examples include sitagliptin, saxagliptin, vildagliptin, and linagliptin
    • Inhibits the DPP-4 enzyme that is responsible for degrading the incretins, glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide (GIP)
    • The increasing incretin levels inhibit glucagon release, which in turn increases insulin secretion and decreases BGLs
    • Carry a low risk of hypoglycemia with exercise
    • Not used in T1DM

    Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

    • Examples include canagliflozin, dapagliflozin, empagliflozin, and erugliflozin
    • Inhibit the reabsorption of glucose in the kidneys, therefore lowering BGLs
    • Can increase the risk of ketoacidosis and UTI
    • Can cause dehydration, so ensure patients are well-hydrated with exercise

    Injected (Non-Insulin) Medications

    • Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

      • Examples include exenatide, dulaglutide, liraglutide, semaglutide, and lixisenatide
      • Works via multiple mechanisms
      • Decreases post-meal glucagon production
      • Delays gastric emptying
      • Increase satiety, leading to decreased caloric intake
      • Not suitable for T1DM
      • May reduce the rate of absorption of oral medications
      • Can increase the risk of hypoglycemia when combined with a sulfonylurea

    • Amylin Analogue

      • Example: pramlintide
      • Works via multiple mechanisms
      • Decreases post-meal glucagon production
      • Delays gastric emptying
      • Increase satiety, leading to decreased caloric intake
      • Indicated for insulin-treated T2DM and T1DM
      • Contraindicated in patients with hypoglycemia unawareness
      • Should not be mixed with insulin (must be injected separately)
      • Can increase the risk of hypoglycemia when combined with insulin

    Insulin

    • Rapid Acting Insulin

      • Do not allow patients to exercise at the peak insulin dose of a rapid acting insulin (first 2 hours following drug administration)

    • Short Acting Insulin

    • Intermediate Acting Insulin

    • Long Acting and Ultra Long Acting Insulin

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    Description

    This quiz covers the pathophysiology of diabetes, including insulin resistance and secretion defects, as well as treatment options for type II diabetes, such as lifestyle management and medication.

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