Presentation by Pierre Boulay (PhD) and François Cholette (MHK) at the Diabetes Perspectives... Ages and Stages Symposium (September 29, 2014)

1. From Fads and Trends to Reality and Research /
De mythes et tendances à réalité et recherche
Pierre Boulay, PhD
&
François Cholette, MHK, R.Kin.

2. We have no relevant financial or nonfinancial relationships in the products or services described, reviewed, evaluated or compared in this presentation.

3. TREND:
A general development
or change in a situation or
in the way that people are
behaving
(http://dictionary.cambridge.org).

4. 
A trend - definition from fashion

may last for 2-10 years and more

often than not they have been a trend or fad before in history

Like Skinny jeans – popular in 1980s,
slowed down and have heightened
again in the 2000s.

5. FAD: A fashion that is taken up with great enthusiasm for a brief period.
http://dictionary.reference.com)

6. Reality, Research &Training principles
vs
Trends and Fads

7. 
1. Overload principle

2. Progression/moderation principle

3. Specificity principle

4. Variation principle

5. Individual differences principle

Other important principles to consider:

6. Diminishing Returns Principle

7. Reversibility principle
Martens, R. (2004) Successful Coaching, 3rd Edition

8. 
To improve fitness levels, an individual must do more than what their bodies are used to do.

When more is demanded, within reason, the body adapts to the increased demand.

FITT: Frequency, Intensity, Time, Type

Are the guidelines meeting this principle?
Martens, R. (2004) Successful Coaching, 3rd Edition

10. 
Gently push your clients’ bodies to adapt to a reasonable physical stress.
Avoid overtraining
Appropriate ratio of exercise/pa : active rest
even walking requires an appropriate ratio
Linked to overload, variation & individuality principle
The running clinic.ca (2006)
Martens, R. (2004) Successful Coaching, 3rd Edition

11. 
Results depends on the type of exercise.

Exercises needs to be specific to attain certain objectives.

Ex. Climbing Mt Tremblant = step master, walking, leg strength, etc.
In sports, importance of being sport-specific.
Martens, R. (2004) Successful Coaching, 3rd Edition

12. 
Goals of variation

Exercise/PA : Active Rest (stretching, etc);

Change exercises/activities to avoid overstressing a part of the body;

Change exercises sequences to continue to overload the body;

Maintains a client’s interest in exercise/PA;

Paradox – ratio of specificity vs variation
Martens, R. (2004) Successful Coaching, 3rd Edition

13. 
Every athlete is different and responds differently to the same exercises/activities

Factors affecting: pretraining condition; genetic predisposition/limit ; gender and race; diet and sleep; environmental factors such as heat, cold, humidity and lifestyle, workstyle, motivation.

No one size fits all

Exercise is like a medication that needs to be prescribed with careful attention

Objectives and personal view of the client
Martens, R. (2004) Successful Coaching, 3rd Edition

14. 
6. Diminishing Returns Principle -

Rate of fitness improvement diminishes over time as fitness approaches its ultimate genetic potential

As fitness levels increase, more work or training is needed to make the same gains.
7. Reversibility principle –
Physical activity benefits ARE reversible
Use it or lose it
Martens, R. (2004) Successful Coaching, 3rd Edition

15. 
Improve fitness level

reduce CVD risk

Improve glycemic control

Maintain muscle mass

Improve mental health

Improve quality of life/ADL

Improve range of motion

And yes, maintain weight / lose fat (if realistic)

…and as you know, much more!

16. De mythes et tendances à réalité et recherche
From Fads and
Trends to
Reality
and
Research

17. Thompson, Walter R. (2013).
Now Trending: Worldwide Survey of Fitness Trends for 2014.
Health & Fitness Journal. Dec 2013. Vol 17 (6)

18. 
Can help your organization in planning future exercise programs, group;

May help the health and fitness industry make some very important investment decisions for future growth and development.

Important business (public health) decisions should be based on emerging trends

not on the latest exercise innovation peddled by late- night television infomercials or the hottest celebrity endorsing a product.

19. 
Survey completed by 3815 health & fitness professionals ONLY ; no clients

commercial (typically for-profit), clinical (including medical fitness), community (not-for-profit), and corporate divisions of the industry

20. -
65% female
Australia, Austria, Barbados, Brazil, Columbia, Costa Rica, Finland, Greece, Hungary, Iceland, India, Indonesia, Israel, Jamaica, Lebanon, Mauritius, Mexico, Netherlands, New Zealand, Nigeria, Peru, Portugal, South Korea, Romania, Saudi Arabia, Serbia, Singapore, South Africa, Spain, Sri Lanka, Switzerland, Taiwan, Thailand, United Arab Emirates, United States, and the United Kingdom.
Many countries
Their could be differences from countries to countries

22. 
Should ONLY be used as a guide

The needs, objectives and personal view of the client needs to be listen to (basic counselling skill).

Could be worthwhile to do an in house survey with clients participating in other programs/services.

25. High intensity interval training (HIIT) describes exercise that is characterized by brief, intermittent bursts of vigorous activity, interspersed by periods of rest or low-intensity exercise.
Gibala. et al. 2012. Physiological adaptations to low-volume, high intensity interval training in health and disease. J Physiol. 590:5: 1077-1084.
Summary of protocols in research typically used to compare HIIT with traditional endurance exercise training on cycle ergometers
Variable
HIIT group
Endurance group
Protocol
Training intensity (workload)
Weekly training time commitment
4-6 x 30 s (3-5 min rest) or 6 x 10 s (60 s rest) – 3 sessions/week
“All out” maximal effort (500 W)
Approx. 10 min (1.5 hr including rest)
40-60 min cycling (5/week)
65 % VO2peak (approx 150 W)
Approx. 4.5 h

26. 
A commonly cited barrier to physical activity is lack of time. Including HIIT in a training programme implies that greater health- enhancing benefits could be gained in less time, making HIIT a more time efficient and attractive option. Moreover, short bursts of activity may address another common limiting factor, lack of motivation, as it may be a more enticing option than the prospect of continuously exercising for an extended period of time.
Gibala. et al. 2012. Physiological adaptations to low-volume, high intensity interval training in health and disease. J Physiol. 590:5: 1077-1084.

27. Adaptations occurring significantly more with HIIT compared to continuous endurance training

Increased VO2peak

Decrease systolic and diastolic blood pressure

Increased HDL, decreased TG

Decreased fasting glucose

Decreased oxidative stress and inflammation

Increased adiponectin, insulin sensitivity and ß-cell function

Increased maximal rate of Ca2+ reuptake

Increased availability of nitric oxide

Increased cardiac function

Increased enjoyment of exercise

Increased quality of life
Weston. et al. 2014. High-Intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br J Sports Med. 48: 1227-1234.

28. Suggested contraindications to high-intensity interval training (HIIT)

Unstable angina pectoris

Uncompensated heart failure

Recent myocardial infarction

Recent CABG or PCI (< 12 months)

Heart disease that limits exercise (valvular, congenital, ischemic and hypertrophic cardiomyopathy)

Complex ventricular arrhythmias or heart block

Severe chronic obstructive pulmonary, cerebrovascular disease or uncontrolled peripheral vascular disease

Uncontrolled diabetes mellitus

Hypertensive patients with blood pressure > 180/110 (or uncontrolled)

Severe neuropathy
** the list should go on ….. and this is not evidence-based. Majority of studies done in patients with a chronic condition are low-risk and well controlled.
Weston. et al. 2014. High-Intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br J Sports Med. 48: 1227-1234.

29. Adapted from Weston. et al. 2014. High-Intensity interval training in patients with lifestyle-induced cardiometabolic disease: a systematic review and meta-analysis. Br J Sports Med. 48: 1227-1234.
Protocol recommendations for high-intensity interval training (HITT) for health and disease
Frequency
Duration
Modality
Intensity
Interval times
Warm-up
Cool-down
3 times per week
30 minutes
Treadmill/hill, cycle ergometer. Increasing speed or incline.
Interval = 85-95 % peak heart rate Rest=low active-70 % peak heart rate
4 x 3-4 min intervals with 3 min recovery or 8-10 x 1 min with 1 min recovery
10 min @ 60 % peak heart rate
5 min @ 50 % peak heart rate
* Future research is needed to establish the optimal protocol of HITT in patients with diabetes and other chronic diseases.

30. Adapted from Kilpatrick. et al. 2014. High-Intensity Interval Training. A Review of Physiological and Psychological Responses. Health & Fitness Journal. 18(5): 11-16.
Recommendations for practitioners
Base prescription
Warm-up at a low to moderate intensity for 2 to 5 minutes. First complete a 1-minute high-intensity work interval at about 90% of max effort.
Then complete a 1-minute low-intensity recovery at about 10 % max effort.
Repeat the work and recovery intervals 10 times for a total of 20 minutes.
Cool-down at a low to moderate intensity for 2 to 5 min
Start slowly
Increase the number of HIIT sessions into an exercise program across time.
Trial and error
Encourage clients to try a variety of HIIT workouts to find one that is enjoyed.
Consider manipulating the duration of the intervals to shorter or longer periods.
Adjust the recovery period for more or less rest between work intervals.
Change it up
Try HIIT exercises indoors and outdoors, with music and without music, alone and with workout partners, etc.
Be careful
Reinforce that intense exercise increases risk and to be cautious when trying new HIIT routines, especially those that require any unorthodox movement or patterns.
This form of training fits somewhat loosely within the umbrella of vigorous exercise and therefore is only appropriate for low-risk individuals, moderate-risk individuals who have been cleared for vigorous intensities by a medical professional, and high-risk individuals who are under direct medical supervision during exercise training.

31. Little, JP. et al. 2014. Journal Applied Physiol. 10 May 2014
Fig 2: Two weeks of high-intensity interval training improves glycemic control. A: average blood glucose concentration measured by continuous glucose monitoring (CGM) over a 24-h period before (Pre) and after (Post) 2 wk of training. B: blood glucose concentration assessed by CGM over 24 h before (Pre; solid line) and after (Post; dashed line) training in a representative subject. Post training CGM data was collected from 48–72 h following the final training session. Values are means SD (N 7). *P 0.05. n=8, 63 yrs of age, A1C 6.9
10 x 60 sec sprint (95 % Wmax, about 100 W) with 60 sec recovery (3 min warm-up at 50 W + 2 min cool-down at 50 W for a total of 25 min). 3 x per week for total of 75 min – 6 sessions total

32. Conclusion
The training protocol involved a total of only 30 min of high-intensity exercise/week and a total time commitment of only 75 min/wk. This is much lower than current physical activity guidelines for T2D that recommend a total of 150 min of moderate to vigorous intensity exercise each week. Given that the majority of individuals with and without T2D do not accumulate sufficient exercise to achieve health benefits and the most common cited barrier to regular exercise is lack of time, our results suggest that low-volume HIIT may be a viable, time efficient strategy to improve health in patients with T2D.
Little, JP. et al. 2014. Journal Applied Physiol. 10 May 2014

33. The impact of 3 small doses (6 x 1 min) of intense exercise (90% HR max) before meals (exercise snacking) versus a single bout of (energy-matched) prolonged continuous (30 min) moderate-intensity (60% HR max) exercise in individuals with insulin resistance on postprandial blood glucose and 24 h glycaemic control.
Francois ME. et al. 2014. Diabetologica. 10 May 2014

34. Francois ME. et al. 2014. Diabetologica. 10 May 2014

35. Francois ME. et al. 2014. Diabetologica. 10 May 2014

36. Francois ME. et al. 2014. Diabetologica. 10 May 2014
Conclusion
“we found exercise snacking to be a novel and effective approach to improve glycaemic control in individuals with insulin resistance. Brief, intense (incline walking) interval exercise bouts undertaken immediately before breakfast, lunch and dinner had a greater impact on postprandial and subsequent 24h glucose concentrations than did a single bout of moderate, continuous exercise undertaken before an evening meal.”

37. 
People with diabetes (including elderly people) should perform resistance exercise at least twice a week, and preferably 3 times per week [Grade B, Level 2] in addition to aerobic exercise [Grade B, Level 2]. Initial instruction and periodic supervision by an exercise specialist are recommended [Grade C, level 3]
Canadian Diabetes Association Clinical Practice Guidelines 2013

38. Canadian Diabetes Association Clinical Practice Guidelines 2013
to near fatigue

39. VS
Endurance resistance
training (20+ reps)
Hypertrophy resistance Training (8-12 reps)

40. Resistance training has become a mainstay of exercise training in type 2 diabetes. However, it remains controversial whether hypertrophy resistance training (HRT: 2 sets : 10-12 reps : 70 % 1 RM) is superior to endurance strength training (ERT: 2 sets : 25-30 reps : 40 % 1 RM) with regard to its effects on glycemic control, muscle mass and strength in older T2D patients.
Egger, A. et al. European Journal of Preventive Cardiology. 2013. 20(6): 1051-1060.
VS

41. In conclusion, 8 weeks of a combined programme of aerobic exercise training with HRT or ERT in T2D led to a significant reduction of body weight, glucose and subcutaneous fatty tissue, as well as a significant increase in physical work capacity and muscle mass. HRT group had sign greater improvement in muscle strength. Since differences between the two resistance training programmes were rather modest, and preferences of patients regarding training modalities and tolerability of heavy weights vary substantially, it appears warranted that training modalities should be left to the patients’ discretion in order to provide a more individualized and thus more attractive exercise training programme, which might lead to improved long term compliance.
Egger, A. et al. European Journal of Preventive Cardiology. 2013. 20(6): 1051-1060.

42. Resistance training intensity guidelines for management of type 2 diabetes
Week
1
4
8
12
16
20
24
Goal intensity (based on % 1RM) a
50 %
55 %
60 %
65 %
70 %
75 %
80 %
Goal repetitions b
10 – 15
8 – 12
8 - 12
8 – 10
8 – 10
8 – 10
8 - 10
a 1 RM = 1 repetition maximum
b Repetition schemes are not aligned with traditional intensity values.
Egger, A. et al. European Journal of Preventive Cardiology. 2013. 20(6): 1051-1060.

43. This recent study support the guidelines and clearly demonstrated that the design of exercise training programs used to treat individuals with type 2 diabetes will have an impact on clinical outcomes.
Combining aerobic exercise with resistance training is the best approach.
(140 min aerobic vs 140 min of resistance vs 110 min aerobic + 30 min of resistance training)

44. 
People with diabetes should accumulate a minimum of 150 minutes of moderate to vigorous intensity aerobic exercise each week, spread over at least 3 days of the week, with no more than 2 consecutive days without exercise [Grade B, Level 2, for T2DM; Grade C, Level 3 for T1DM]
Most Canadians and people living with diabetes currently do not meet these targets.

45. Tudor-Locke, C and Schuna, J.M. Frontiers in endocrinology. Nov 2012; vol. 3; article 142

46. Source: Colley, R.C. et al. Statistics Canada, Catalogue no. 82-003-XPE. Health Reports, Vol 22, no 1 Mars 2011.
An estimated 15% of Canadian adults accumulate 150 minutes of moderate-to-vigorous physical activity (MVPA) per week; 5% accumulate 150 minutes per week as at least 30 minutes of MVPA on 5 or more days a week.
Men are more active than women and MVPA declines with increasing age and adiposity.
Canadian adults are sedentary for approximately 9.5 hours per day (69% of waking hours).
Men accumulate an average of 9,500 steps per day and women, 8,400 steps per day. The 10,000-steps- per-day target is achieved by 35% of adults.

47. Savage, P.D. & Ades, P. (2008) Journal of Cardiopulmonary Rehabilitation and Prevention. 28:370-77.

48. Tudor-Locke et coll. 2012. A step-defined sedentary lifestyle index: < 5000 steps/day. Applied Physiology, Nutrition, Metabolism.
Step-defined sedentary lifestyle index for adults. MVPA, moderate-to-vigorous physical activity.
30 min / day

49. Tudor-Locke, C and Schuna, J.M. Frontiers in endocrinology. Nov 2012; vol. 3; article 142
Walk more, sit less, and exercise

51. 
Exercise prescription for health, which is more important : Exercise more, Walk more or Sit less ?
Expected trends in 2015
Based on an article from ‘The Huffingtonpost’
Opinion-based only!
http://www.huffingtonpost.com/jill-s-brown/fitness-trend-forecast-fo_b_5753458.html

52. 
1- HITT

2- Recovery/Self-Care

Train Hard, Recover Harder

3- Physical activity monitors :

Will this be helpful to improve behavior changes in our society ?

4- Online Workouts

5- Short Workouts

6- Kids Fitness

53. 
Important business and public health decisions should be based on emerging trends.

Choosing the right exercise (trend) and applying the training principles to attain/reach a client’s goal should be taken into account when creating your client’s plan.

54. 
New HITT research indicates that this type of exercise could be a valuable solutions for your low-risk clients. More research is needed for safe exercise prescription with a high-risk population.

Resistance training is important to your diabetic client’s health. New resistance training research shows that HRT and ERT have a similar impact on T2D. HRT or ERT should be included in your diabetic patients’ exercise program.

Your intervention should focus as much on sitting time than on physical activity and exercise.

55. Pierre Boulay, PhD
Professeur/Professor
Faculté d’éducation physique et sports
Université de sherbrooke
Pierre.Boulay@usherbrooke.ca
François Cholette, MHK, R.Kin.
Kinésiologue/Kinesiologist
Santé & Performance
Hexzone
Health & Performance
info@hexzone.ca