HYPERLIPIDEMIA, HYPERTENSION, and DIABETES

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HYPERLIPIDEMIA, HYPERTENSION, and DIABETES
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Hyperlipidemia

• Arteriosclerosis arteries undergo changes
  normally associated with the aging process
• Atherosclerosis pathologic phenomenon resulting
  in obstructive lesions primarily in the aorta,
  coronary, and carotid arteries

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Atherosclerosis

• Atherosclerosis is a multi-factorial process
• Cigarette smoking
• Poor blood lipid profile
• HTN
• Genetic factors, diabetes
• Sedentary lifestyle
• Male gender
• Obesity

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Anatomy of the Artery

• Endothelium serves as a barrier between the
  blood and the artery wall
• Lumen the channel for blood flow within the
  artery
• Intima area of the arterial wall in which the
  obstructive lesions of atherosclerosis form
• Media contains smooth muscle cells advanced
  atherosclerosis occurs in this layer

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Progression of atherosclerosis (CAD)

• Injury to endothelial cells
• Endothelial dysfunction
• Increased permeability to substances in the blood
• Increased thrombogenesis
• Greater tendency for adherence of substances to
  the endothelial cells

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Progression of CAD, cont.

• Platelet aggregation and release of growth
  factors and vasoactive agents
• Plaque forms (hardened mounds)
• Artery blockage
• Advanced atherosclerotic plaques without
  intervention

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Plasma Lipoproteins

• Water-soluble complexes of lipids (cholesterol,
  TGs, phospholipids) and specific lipoproteins
  (apolipoproteins)
• Five classes have been described
• LDL transports 60-70 of the total cholesterol
  atherogenic particle (causes CAD)primary target
  of therapy
• HDL transports 20-30 of total cholesterol
  lipoprotein inversely related to CAD by mediating
  reverse cholesterol transport remove from sites
  of deposit and deliver to liver for excretion

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Plasma Lipoproteins

• TGs fat in the blood atherogenic?
• Chylomicrons TG rich particles produced in the
  intestine after a fatty meal atherogenic?
• VLDL secreted by liver into circulation and
  transport TG and cholesterol may be a risk for
  atherosclerosis

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Recommendations to Lower Cholesterol

• Fasting lipid profile
• Decrease consumption of fats and cholesterol to
  lt30 (Dean Ornish Study)
• Exercise increase HDLs reduce TGs
• Cease smoking
• HTN and diabetes worsen blood lipid profile
• Moderate alcohol intake may increase HDLs
• Weight loss?

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HYPERTENSION (chronically elevated BP)

• Most common cardiovascular disease in human
  populations (15-20 25-30 in black population)
• Product of Q and total peripheral resistance
• systolic BP highest arterial pressure of
  cardiac cycle occurring immediately after
  contraction of the left ventricle
• diastolic BP lowest arterial pressure of
  cardiac cycle occurring during relaxation of the
  heart

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Hypertension, continued

• Primary HTN (essential HTN) accounts for 95 of
  patients cause is generally unknown
• Multiple regulatory mechanisms contribute to the
  evolution of primary HTN
• Secondary HTN caused by specific endocrine or
  renal abnormalities (i.e. tumors of the adrenal
  medulla and cortex)
• Effects of HTN
• left ventricular hypertrophy arteriosclerosis
  stroke end-stage organ failure (silent killer)

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Hypertension, continued

• During exercise - SBP should increase b/c Q
  increases DBP should stay same or go down a bit
• Recommendations to decrease BP include
• exercise (decrease SBP 8-10 mmHg, 5-8 mmHg DBP)
• reduce sodium intake
• weight control
• medications when all else fails

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Diabetes Mellitus

• Major public health problem affecting nearly 6
  of the US population (16 million)
• Diabetes is a chronic metabolic disease c.b. an
  absolute or relative deficiency of insulin
  resulting in hyperglycemia
• Leading cause of adult blindness and amputation
• Major cause of renal failure, MIs and stroke

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Classes of Diabetes Mellitus

• Type I Insulin-Dependent (IDDM)
• 5-10 of the 16 million diabetics in the US
• absolute deficiency of insulin
• Type II Non-Insulin-Dependent (NIDDM)
• 80-90 of the 16 million diabetics in the US
• metabolic alterations cause relative deficiency
• Typically occurs in overweight adults over 40
  years

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Classes of Diabetes Mellitus

• Impaired Glucose Tolerance has been recognized as
  a precursor to diabetes onset
• Fasting plasma glucose is lower than that
  required for diagnosis of diabetes (gt110mg/dL)
• Increased risk for developing diabetes (but
  progression is not a certainty)
• Gestational Diabetes
• Occurs in 2-3 of women during pregnancy and is
  resolved postpartum

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Effects on the Exercise Response

• Exercise is considered to be one of the
  cornerstones of Type II Diabetes care
• The effect of diabetes on exercise is dependent
  upon several factors
• Use, type timing of medication
• Blood glucose level prior to exercise
• Intensity, duration type of exercise
• Complications (patterning of syndrome X)

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Effects of Exercise Training

• Possible improvement in blood glucose control
• Improved insulin sensitivity (48 hour
  effect)/lower Rx requirement
• Reduction in body fat
• Prevention of Type II diabetes
• Cardiovascular benefits

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Exercise Considerations

• If blood glucose is 80-100 mg/dL, correct by
  carbohydrate ingestion (prevent hypoglycemia)
• If blood glucose is gt 250-300 mg/dL and ketones
  are present, they cannot exercise
• One hour of exercise requires 15 gm of CHO
  either before or after exercise
• Keep source of rapidly acting CHO available
  during exercise
• Recognize symptoms of hypoglycemia

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Exercise Considerations

• Avoid exercising at peak insulin times insulin
  injection should not be given to exercising limb
• Exercising late in the evening increases risk of
  nocturnal hypoglycemia
• Practice good foot care and wearing proper shoes
• Engage in aerobic exercise 4-7 days/week for
  optimal control of blood glucose/insulin dosage