Andrew Farquhar MD (biography and disclosures)
What I did before
As a GP with a special interest in Diabetes and a long-term firm believer in the benefits of regular exercise it’s fair to say I devote much time and effort to encouraging my patients to find time to be active, to eat a healthy diet (with a vegetarian emphasis), and to continue their efforts at weight loss.
Type 2 diabetes (T2D) is a lifestyle disease. Therefore it is reasonable that the first goal of management is to encourage lifestyle change to reduce or reverse the underlying metabolic derangements. Most emphasis has been placed on obesity and weight loss as they are the 2 key factors in the cause and prevention/management of Type 2 diabetes.
Weight loss is incredibly difficult for most people to achieve and maintain. I regularly see patients stressed out at their failed efforts to lose weight. Most overweight patients, despite all exhortations, have given up trying because it ends in failure, makes them depressed and adds to the negative image they may already have of themselves.
What changed my practice
In 2009 at the World Diabetes Congress in Montreal I was invited to debate the relative merits of exercise vs. diet in the management of diabetes. I opted to argue for “exercise”.
Preparing for this debate was enlightening. A fascinating paper by Ross and Janiszewsky raised the question “Is weight loss the wrong goal?” (3). I’m now inclined to believe that it is!
The obesity epidemic has spawned a multibillion dollar diet industry. Diets come and go, with little solid evidence of long term benefit. Conversely the benefits of exercise are powerfully evidence based. Compelling data indicate that regular physical activity may be at least as important as diet in terms of both prevention of diabetes and avoidance of complications – especially heart attacks and strokes, which account for up to 80% of deaths. (1, 6) In diabetes, low fitness far exceeds the risks associated with modest obesity and is one of the strongest predictors of all-cause mortality, considered to be on a par with smoking. (4) Physical activity can be as powerful as glucose lowering medication with fewer side effects. (5) High quality studies show many of the benefits of increased physical activity are independent of weight loss and include not only multiple physical benefits (including a reduction in certain forms of cancer, dementia, osteoporosis) but also the very significant benefits on quality of life, mood and wellbeing, self-esteem, insight, and overall enhanced coping skills in managing and living with a chronic disease such as diabetes.
It is no exaggeration to say that regular exercise is the cheapest, safest and most effective means to long term health. Inactivity or “sedentariness” may be public health enemy #1!
What I do now
I direct more effort to encouraging physical activity as a critical tool in the management of T2D. I emphasize a healthy diet but stress that weight loss is not the primary goal. (“Waist loss” is a more useful concept and indicates a drop in visceral obesity – a powerful indicator of CV risk (2) I use a measuring tape in preference to scales.)
I emphasize that diabetes is a complicated disease that requires complicated treatment and an informed and aggressive approach from both physician and patient alike. The patient is the primary stakeholder – his diabetes is his responsibility. Multiple drugs are essential, but so too is a firm commitment to a lifestyle that includes prioritizing at least 30 mins a day to brisk walking or an equivalent form of exercise.
The evidence is unequivocal. We should all put far more emphasis on encouraging patients to be more active. A commitment of 30 mins in 24 hours is not huge and even if (as is likely for many) there is no weight loss, the multiple other benefits must be stressed.
I encourage patients to make that 30 mins in their day a priority time – “see it as an investment in your arteries – more vital to you than an investment in your bank account” A pedometer is an inexpensive and powerful motivator for many people. The goal is 10,000 steps a day. (7)
I give my patient a preprinted prescription using the “FITT” concept : Frequency 5 days/week; Intensity moderate to vigorous ie can converse without being overly short of breath; Time 30 mins per day; Type Aerobic 5/7 Resistance 3/7 (aerobic exercise 5 days per week and resistance exercise 3 days per week).
I tell my patients it is better to be fat and fit than lean and unfit. I frequently remind them of the benefits of regular activity other than weight loss, viz a reduction in cardiovascular risk, improved lung function, stronger muscles and bones, a reduced risk for various types of cancer and an overall increase in energy level. There is probably no system in the body that is not damaged by diabetes. Conversely there is probably no organ system in the body that does not benefit from regular exercise.
Until very recently the hard evidence for the benefits of exercise was vague and ill defined. That has all changed – the benefits of an active lifestyle cannot be overstated.
*For a unique and fascinating overview please check out reference (8)
References: (Note: Article requests might require a login ID with CPSBC or UBC)
- Lee DC, Sui X, Church TS, et al. Changes in fitness and fatness on the development of cardiovascular disease risk factors. J Am Coll Cardiol 2012; 59:665-672. (View article with CPSBC or UBC)
- Leiter LA, Fitchett DH, Gilbert RE, Gupta M, Mancini GBJ, McFarlane PA and Ross R, and the working group. Identification and Management of Cardiometabolic Risk in Canada: A Position Paper by the Cardiometabolic Risk Working Group (Executive Summary) Cdn J Cardiol 27(2): 124-131, 2011. (View article with CPSBC or UBC)
- Ross R, and Janiszewski PM. Is weight loss the optimal target for obesity-related cardiovascular disease risk reduction? Cdn J Cardio 24: 25D-31D, 2008 (View article with CPSBC or UBC)
- Church TS et al. Exercise capacity and body composition as predictors of mortality among men with diabetes..Diabetes Care 2004;27(1);83-88 (View)
- Knowles WC et al Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin N Engl J Med. 2002; 346(6;) 393-403 (View)
- CDA 2008 CPG for the Prevention and Management of Diabetes in Canada :Can J Diabetes 2008; 32(suppl1) S1-S201 (View)
- Tudor-Locke, Catrine (June 2002). “Taking Steps toward Increased Physical Activity: Using Pedometers to Measure and Motivate” <http://www.fitness.gov/pcpfsdigestjune2002.pdf>. President’s Council on Physical Fitness and Sports Research Digest, Washington, DC
- 23 1/2 hours – Dr. Mike Evans. website http://www.myfavouritemedicine.com/
Additional reading:
http://www.bcguidelines.ca/guideline_diabetes.html
http://www.health.gov.bc.ca/pharmacare/pdf/infosheet-on-diabetes-therapy.pdf
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This will definitely bring earlier gratification to those people whose goals are to lose hundreds of pounds and may otherwise see no dramatic benefit to their changes in diet. It is still possible to feel great – or at least better – while still being overweight. Exercise will certainly provide benefit long before the weight is (if ever) gone!
Excellent thoughtful article.
I was aware of Dr. Mike Evans’ video 23-1/2 hours. Another doctor had set up a quick link to it at:
http://tinyurl.com/couchp2
I incorporate it into my “EXERCISE PRESCRIPTION” which I write to my patient. I am able to store this a personal favorite prescription which is able to be chosen in the same way as a drug and printed out on a prescription form.
With Dr. Farquhar’s suggestions, I have modified my prescription now to state:
EXERCISE PRESCRIPTION
Frequency: 5 days/week
Intensity: moderate to vigorous (i.e. can converse without being overly short of breath)
Time: 30 mins per day
Type: Aerobic 5 day/week, Resistance 3 days/week
Before you start your exercise program, please watch this 10 minute video on the benefits of exercise at: http://tinyurl.com/couchp22
Makes sense, perhaps more doable for most patients.
Be sure to check out the 23 1/2 hours video referenced above at http://www.myfavouritemedicine.com/ — it’s truly inspiring and a great motivator for both docs and patients!
This doable and works quite well with my patients, much easirer in May than November….
Great ideas on exercise and diabetes and well supported and amplified by Dr. Mike Evans video 23 and 1/2 hours for all health benefits.
thanks for the link.
very good, I always tell patient to walk 1 hour a day 3times a week, now
i will tell them 5 times a week.
30 mn a day would be good for most patient.
Excellent summary of an entirely do-able approach in the office. Part of what we do every day is a coaching function to help folks stay motivated to be more active.
I feel very strongly about this and promote exercise to anyone that will listen. I speak regularly to a successful weight loss program that is run by a local Nurse Practitioner. I have spoken to groups at the annual Health Fair in town. I think that exercise should, along with other healthy lifestyle choices be taught as an important component of therapeutics in medical school. Most of the chronic disease that we see day to day in our offices is a consequence of poor lifestyle choices. I think that if our health care system is to survive these issues must be addressed and I think many heaklth care providers need to begin dealing with this in their own lives. Thanks for the excellent article.
How effective is your aproch in the treatment of your patient?
I agree that the focus on diet has been far too overdone at the expense of increased physical activity. And though it’s better to be fat and fit than slim and unfit, caloric intake must still match output to prevent continuing fat lay down. So diet is important, but it’s focus in practise, needs to be modified.
From personal experience, regular exercise often leads to less focus on food, translating to less calorie intake.
Therefore I think, healthcare providers must advocate both diet and regular exercise, but shift the focus of diet from weight loss to nutritionally adequate intake (i.e. Avoiding empty high calorie or high fat foods)
This article gives me one more piece of information to pass on to my patients about the importance of exercise despite the fact that they may not notice a huge weight loss. It is better to be overweight and fit than lean and not fit is an encouraging message to give to patients who are frustrated with their attempts to lose weight.
I think we are still looking for that one bullet/pill that gives the most benefit. Health and disease is multifactorial. There is not one thing that keeps you healthy or one thing that keeps diabetes away. I believe diet, exercise, stress reduction, supplements, positive thinking, and medications are important in diabetes. Each personality is different, and will be attracted to his/her own path to follow. Our aim is to provide good advise based on good evidence as we know it so that they can make informed decisions. As everybody knows what was taught 20 years ago and what is taught now has changed and some concepts have come a full circle.
I work n the wt loss business – diet in my opinion is far more important than exercise and the change in body image resulting from wt loss encourages people to take up exercise
i agree