Distance learning health care degree

Each issue of Diabetes and Primary Care contains a continuing education module. Each module carries 2 hours PGEA accreditation for GPs; nurses can complete the supplement to use towards their PREP requirements. Participants should be able to complete the supplement within 2 hours. This can then be submitted to the address on the application form for assessment and feedback. Certificates will be awarded to all health professionals completing the supplement to the required standard. No payment is required.

Standards to be achieved

To receive a certificate, the answers provided must meet the following criteria:

1. All questions within the supplement must be answered.

2. The minimum number of answers to individual questions should be given where specified.

3. Factual knowledge around the subject area, plus the case studies, will be compared with specimen answers for accuracy.

4. Questions around your own practice will be assessed for an adequate level of completion. Brief answers are acceptable.

The feedback will indicate one of two things:

a) You have successfully completed the questions and will be awarded accreditation and a certificate.

b) Your answers have been inadequate, and comments will be provided.

You will also receive a set of specimen answers against which to compare your own work.

Section 2. This section is provided for readers wishing to refresh their knowledge. Readers may choose to defer reading this section until completion of the rest of the module.

The epidemic of type 2 diabetes constitutes a major health problem for both westernised and newly developing countries. The direct costs associated with treating diabetes in Britain accounts for a substantial part of the NHS budget. This includes about 9% of all hospital costs ([pounds sterling]2 billion a year) together with spending within the community and general practice. (Audit Commission, 2000). Additionally, there are indirect costs, including those affecting the national economy, e.g. loss of working days and the provision of sick pay, and -- perhaps the most difficult to quantify -- the costs to patients and their families involved in the day-to-day management of the condition.

Type 2 diabetes is characterised by a clustering of metabolic, cardiovascular and haemodynamic disorders (Whitelaw and Gilbey, 1998) and the potential role of exercise in ameliorating this condition is underlined by the wealth of research completed to date. Many of these disorders have been shown to be attenuated by an increase in physical activity (Eriksson et al., 1997).

It is possible that the use of exercise as an adjunct to diabetic treatment today has been compromised by an inconsistency in the methodologies and outcomes of past studies (Cononie et al, 1994; Rogers et al, 1998; Fuji et al, 1982) and also by the lack of exercise scientists within national diabetes care teams.

Type 2 diabetes

Genetic as well as environmental factors, such as physical inactivity, obesity and stress, contribute to the alteration in glucose homeostasis that has the potential to progress from impaired glucose tolerance to overt type 2 diabetes.

Type 2 diabetes is characterised by fasting hyperglycaemia in combination with elevated, normal or decreased levels of insulin. This reflects:

* The reduction in peripheral glucose utilisation as skeletal muscle becomes resistant to the action of insulin.

* The stimulation of central glucose production concomitant with a reduction in hepatic insulin sensitivity

* [beta]-cell dysfunction (Lillioja et al, 1993).

Chronic hyperglycaemia has been identified as a contributor to the development of the organ pathologies associated with type 2 diabetes (Zinman and Vranic, 1985; Moltich, 1988).

Other major contributors to insulin resistance and the development of this condition are the degree of obesity and the central distribution of adipose tissue (android obesity) (Horton, 1983: Ivy, 1997) and the dyslipoproteinaemias and hypertension seen in individuals with type 2 diabetes (Steiner, 1994).

What's in a name?

Terms commonly found within the supporting literature include: Physical activity, describing any human movement involving an overall expenditure of energy; exercise, by contrast, implying that the physical activity is planned and repetitive with a view to either maintaining or improving the level of physical fitness; physical fitness which relates to the ability to perform specific tasks and can therefore be used to monitor the effectiveness of an intervention programme or a lifestyle change.

The rationale of exercise

The rationale of exercise in the management of type 2 diabetes has been well established in the literature. Bedrest studies have demonstrated that physical inactivity reduces the ability of insulin-sensitive skeletal muscle to clear glucose due to the rapid development of insulin resistance and a reduction in glucose tolerance (Lipman, 1972). Conversely, both glucose tolerance and insulin resistance can be improved with regular exercise via the mechanism of increased activity of the glucose transport proteins (specifically GLUT-4) and the enzymes associated with the storage and oxidation of glucose within skeletal muscle (Lillioja et al, 1986; Goodyear et al, 1992). The speed with which insulin resistance responds to exercise can be used to help determine the frequency that is needed to maintain this overall improvement in response.

Exercise creates a negative energy balance that results in the preferential loss of central adipose tissue and may therefore attenuate the increase in insulin resistance that is seen in the obese state. The reduction in android obesity serves to improve the control over blood free fatty acid (FFA) levels that in turn promotes the clearance of glucose peripherally and reduces the central production of glucose (Nestal et al, 1978; Lehmann et al, 1995).

Individuals with type 2 diabetes often have a greater incidence of both hypertension and dyslipidaemia, factors that are associated with a higher risk of cardiovascular disease. A three-month exercise intervention in a small trial of 16 type 2 patients demonstrated the value of exercise in the amelioration of this increased risk (Lehmann et al, 1995).

Patient evaluation and considerations

Before commencing any exercise programme, individuals with type 2 diabetes require a comprehensive medical examination to assess their risk when exercising. An evaluation will include due consideration to the following areas:

* Level of metabolic control

* Degree of macro- and microvascular disease

* Evidence of peripheral or autonomic neuropathy

* Individual physical characteristics, e.g. BMI and age

* Duration of diabetes

* Therapeutic status.

A number of recommendations are detailed in the joint Position Statement on Diabetes Mellitus and Exercise by the American College of Sports Medicine and American Diabetes Association (1997). Prospective studies have characterized individuals living with type 2 diabetes as >55 years with a BMI>30 and hypertension (Williams et al, 1995). They are also characterised by a lifestyle that does not include the recommended 30 minutes of moderate daily physical activity (Pate et al, 1995). Therefore, the success of any exercise intervention will rely on a programme that acknowledges the characteristics of this population of potential exercisers. Most importantly, the activities chosen need to reflect personal preferences so that individuals can enjoy the programme and exercise in a comfortable environment. Any programme should be realistic in the setting of goals and progressive in nature but still aim to minimise the risk of muscle and joint injuries and cardiovascular complications. This can be achieved through preffering non-weight-bearing exercise, e.g. swimming or cycling and avoiding high-resistance anaerobic exercise, which significantly increases arterial blood pressure.

The benefits of the exercise programme should be apparent to the individual. These may include an improvement in HbAlc, lowering of arterial blood pressure and increase in general wellbeing.

The prescription

The FITS exercise formula suggested for effective type 2 diabetes management (shown in Table 1) reflects the wealth of data that has been generated since early preinsulin studies (Allen et al, 1919).

A general recommendation is that any exercise session includes both a warm-up and a warm-down period. Ideally, the warm-up will consist of 5-10 minutes of aerobic activity at approximately 40% age-HRmax followed by 5 minutes of gentle static stretches principally for the muscle groups being mobilised. Similarly, a 5-10 minute active warm-down starting at a comparative exercise intensity and tapering to the preexercise level reduces the incidence of muscle and joint injuries. A planned session of spring cleaning or gardening should be no exception to this recommendation.

Practical considerations