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The effects of exercise on prevention and treatment of metabolic syndrome Eun-Jung Rhee Department of Endocrinology and Metabolism Kangbuk Samsung Hospital Sungkyunkwan University

오늘말씀드릴내용 대사증후군의전반적개요 운동의효과 : 근육, 지방세포 대사증후군과운동의관계 Clinical data 운동의양상에따른예후 운동의효과-실제 data를중심으로 운동의방법

The Metabolic Syndrome Lakka TA et al. APNM 32:76-88, 2007

Physical activity in the etiology of the metabolic syndrome Lakka TA et al. APNM 32:76-88, 2007

당뇨병전기정상정상당뇨병당뇨병정상정상공복혈당 장애 정도에따른대사증후군유병율 78-84% 당뇨병전기고혈당 42-64% 내당능 장애 당뇨병전기10-15% 공복혈당 Adapted from ADA and Isomaa et al. Diabetes Care 2001:24:683 경구포도당검사

대사증후군의유병율 OH SW. DMJ 24:561-566, 2011

Prevalence of the metabolic syndrome among 40,698 Korean metropolitan subjects (male) Lee WY et al. DRCP 65:143-149, 2004

Prevalence of the metabolic syndrome among 40,698 Korean metropolitan subjects (female) Lee WY et al. DRCP 65:143-149, 2004

Diagnosis of metabolic syndrome Alberti KGMM et al. Circulation 120:1640-45, 2009

Physical activity 의정의 Physical activity: any movement (or force) exerted skeletal muscle that leads to an increase in energy expenditure above rest Exercise: subcomponent of physical activity that is planned or structured Physical activity level (PAL): TEE/BMR (TEE: total energy expenditure, BMR: basal metabolic rate)

Physical activity energy expenditure (kcal/min) over 24-h period in 4 different middle-aged men assessed by accelerometry Thompson et al. Physiol Rev 92:157-191, 2012

Metabolic pathways of adipose tissue fat, storage and mobilization Thompson et al. Physiol Rev 92:157-191, 2012

Acute (dynamic) and sustained (static) changes in adipose tissue both contribute to the overall response to exercise training or increased physical activity

Mechanisms evolved in acute exerciseinduced glucose transport

Acute exercise induces GLUT4 translocation in skeletal muscle in normal and T2DM patients In 5 normal subjects and 5 T2DM patients, translocation of GLUT4 to the plasma membrane of skeletal muscle (vastus lateralis) assessed Kennedy JW et al. Diabetes, 1999

Exercise increases sensitivity of glucose uptake to insulin in human muscle Wojtaszewski et al. J Appl Physiol 93:384-392, 2002

Glucose utilization and insulin-stimulated glucose utilization after cessation of exercise in rats Garetto et al. Am J Physiol 246:E471-475, 1984

Effects of exercise on mitochondrial protein expression in human skeletal muscle In 24 subjects : young sedentary (YS), young active (YA), old sedentary (OS), old active SIR1 PGC-1α Bori A et al. Exp Gerontol, 2012

Effects of exercise on mitochondrial protein expression in human skeletal muscle AMPK-A2 AMPK-B2 Bori A et al. Exp Gerontol, 2012

Effects of exercise on mitochondrial protein expression in human skeletal muscle NRF1 TFAM Bori A et al. Exp Gerontol, 2012

Physical activity and dyslipidemia Single bouts of exercise: TG 감소, HDL-C 증가 Endurance training: HDL-C 증가 Aerobic exercise training: LDL-C, apob 감소, LDL particle size 증가, apoa 증가, TG 감소

Physical activity and blood pressure 운동중에는혈압이증가하나 20 분이상의운동후 2-4 시간후에는다시떨어짐 고혈압이없는사람에서는수축기혈압이 single bout 의운동후에는 8-10 mmhg, 이완기혈압은 3-5mmHg 감소하고, 고혈압이있는사람에서는 2 배정도더효과가있다. 기전 : 체성분의향상, 인슐린저항성의개선, 내피세포기능의향상, 자율신경계이상의향상

Effect of aerobic exercise on blood pressure : meta-analysis of 54 RCTs Aerobic exercise reduces blood pressure in both hypertensive and normotensive persons. Ann Intern Med 36:493-503, 2002

Exercise and antioxidants Golbidi S et al. Exp Diabetes Res, 2012

The contracting muscle signal Justyna SZOSTAK et al. Clinc Sci 21:91-106, 2011

Anti-inflammatory effects of exercise effects of IL-6 Petersen AMW et al. J Appl Physiol 98:154-1162, 2005

The effects of RT and AT on insulin sensitivity in overweight Korean adolescents Suh SH et al. DMJ 35:418-426, 2011

The effects of exercise training on plasma markers of inflammation conflicting results In a 6-month RCT, diet and exercise together reduced plasma CRP, IL-6 However, the opposite reported Mechanisms: decreased body fat, body composition 향상, proinflammatory cytokine 의감소, antiinflammatory cytokine 의증가, antioxidant 의증가

Impaired muscle AMPK activation in the metabolic syndrome may attenuate improved insulin action after exercise training Layne AS et al. JCEM 96:1815-1826, 2011

Cardiorespiratory fitness and metabolic syndrome

Lower Resting Metabolic Rate (RMR) is associated with impaired CRF in obese individuals In 64 obese individuals with direct assessment of RMR and CRF via breath-by-breath measurement of oxygen consumption and CO production at rest and exercise Miller WM et al. Obesity 20:505-511, 2012

Cardiorespiratory fitness and metabolic risk In 59,820 men and 22,192 women in Cooper Center Longitudinal Study (CCLS) who performed CRF assessment with maximal exercise testing from 1970 to 2009 GrundySM et al. AJC109:988-993, 2012

Cardiorespiratory fitness and metabolic risk GrundySM et al. AJC109:988-993, 2012

CRF attenuates metabolic risk independent of abdominal subcutaneous and visceral fat in men In 297 healthy men with CT or MRI imaging Diabetes Care 28:895-901, 2005

대사증후군에대한운동의효과 - Diabetes Prevention Program - DPP: IFG 3000 여명을 3.2 년간생활습관군, metformin, 위약으로나누어당뇨병발생여부를추적관찰함 Metformin 850 mg bid, 7% weight loss, 주당 150 분운동 Orchard TJ et al. Ann Intern Med 142:611-619, 2005

Development of metabolic syndrome by intervention group in the DPP 53% 47% 38% 생활습관군이대조군에비해 41%, metfomin 군에비해 29% 대사증후군위험율을감소시킴 Orchard TJ et al. Ann Intern Med 142:611-619, 2005

Resolution of metabolic syndrome by intervention group in the DPP 18% 23% 38% Orchard TJ et al. Ann Intern Med 142:611-619, 2005

Changes in insulin resistance with RT, aerobic training, and RT+AT Davidson LE et al. Arch Intern Med 2009;169:122-131

Risk of cardiovascular mortality in men with diabetes across levels of fitness

Low level of leisure-time physical activity and CRF predict development of MS In 612 middle-aged men without MS at baseline 4-year follow-up Laaksonen DE et al. Diabetes Care 25:1612-1618, 2002

Treatment of metabolic syndrome with exercise: The HERITAGE Family Study Exercise program - 3 sessions per week for 20 weeks - Participants started at 55% of their baseline VO2max for 30 min per session and progressed in intensity of duration every 2 wks after a standardized protocol until 75% VO2max for 50 min per session for final 6 wk - Counseled at baseline and 10 wks Katzmarzyk PT et al. Med Sci Sports Exer, 2003

What kind of exercise? 1990 년대까지는대부분유산소운동이권유됨. 대부분의국가에서걷기를가장흔한 recommendation 으로삼고있었음 최근빠른걷기나다른종류의중등도유산소운동이효과가있다는연구결과들이있다. Unstructured physical activity, low intensity daily activities: 아직은확실하지않다. What about resistance training?

Conceptual model of a resistance training and potential effect on energy expenditure Am Coll Sports Med, 2009

Sarcopenia: a serious problem in the elderly.. Sarcopenia: loss of muscle mass associated with aging Main cause of muscle weakness in the old age -> T2DM, IR Etiology: loss of motorneurons, muscle cell apoptosis, muscle fibers decrease 50 세이후부터한해에 0.46kg 의근육이줄어드는것으로알려져있다.

Sarcopenia: a serious problem in the elderly.. 근육은 glucose 와 TG disposal 의 target organ 이고 RMR 의중요한 determinant 즉, 근육의소실은 muscle strength 의감소, RMR 의감소, lipid oxidation 의 capacity 감소, 복부비만의증가로이어짐 Aging 에따른 adiposity 의증가는근육에서의 insulin-mediated glucose uptake 을감소시킨다. 따라서근육량을유지하는것은비만, T2DM, dyslipidemia 등의대사질환의예방에매우중요하다.

Grip strength and the metabolic syndrome: Hertforshire Cohort Study: cross-sectional Sayer AA et al. Q J Med 100:702-73, 2007

The effects of RT on metabolic parameters: meta-analysis Strasser B et al. Sports Med 40:397-415, 2010

Comparison of aerobic versus resistance exercise training effects on metabolic syndrome (STRRIDE-AT/RT) RT training 3 sessions per week 3 sets of 8 to 2 repetitions on 8 Cybex weight lifting machines 4 upper body and 4 lower body Bateman LA et al. Am J Cardiol 108:838-844, 2011

Effects of exercise modes on changes in MS and the components Bateman LA et al. Am J Cardiol 108:838-844, 2011

How much of RT? Still controversial due to the heterogeneity of the studies

Lifecorder

체중감량과유지를위한운동의원칙 ( 미국스포츠의학회 position stand 2009) 원칙 체중증가를막기위한운동. 주 150~250 분의운동 (energy equivalent of 1200 to 2000 kcal/wk) 이성인에서 3% 이상의체중증가를막는다. 체중감량을위한운동. 주당 150 분미만의운동이최소의체중감량을, 주당 150 분이상의운동이중등도의체중감량을 (~2 3 kg), 주당 225 420 분이상의운동이 5~7.5-kg 의체중감량을가져오며운동량과비례한다. 체중유지를위한운동. 보통주당 200~300 분의운동이체중감량후이를유지하거나증가를막기위해서필요하나, 많이할수록더좋다. 그러나증거불충분. 운동과식사조절. 운동은, 식사조절이적당할때는증가시키나, 식사조절이너무심할때는그효과를내지못한다. 저항성운동 (Resistance training) 이체중감량에미치는영향. 아직까지는 RT 이유산소운동만큼체중감량에효과적이라는결과는없다. Lean mass 를증가하거나유지하는데도움을준다거나지방양을감소시킨다는증거도불충분하며, 만성질환의위험인자들을개선하는데도움을준다는연구는있다 (i.e., HDL-C, LDL-C, insulin, blood pressure). 증거 A B B A B Med Sci Sports Exercise, 2009

1 단계 : 신체활동증진

직업이노동인데, 이게운동이지 집안일이얼마나힘든데, 이게운동이지

신체활동 신체의모든움직임 - 직업적신체활동 ( 업무, 일 ) - 여가신체활동 ( 운동, 스포츠 ) 운동 체력을유지시키거나 향상시키기위해행해지는 계획적, 반복적신체활동

몸을많이움직이자! 120kcal /day = 5kg/year 설거지기계 -> 자가설거지엘리베이터 -> 계단자가용 -> 걷기 엘리베이터 계단 (Lanningham et al 2003)

서있기껌씹기움직거리기계단오르기활동별칼로리소모량앉기걷기1.6km/h 걷기3.2km/h 걷기4.8km/h (Levine 2004)

생활습관을바꾸자! 1. 가까운거리는걸어다니기 2. 걸을때는의식적으로속보로걷기 3. 에스컬레이터대신계단이용하기 4. 틈틈이스트레칭실시하기 5. 차는목적지보다멀리주차하여걷는시간늘려주기 6. 텔레비전시청시직접움직여서채널변경하기

2 단계 : 규칙적인운동

운동검사전위험성진단 1 개이상이해당되는경우의사와상의후운동참여! 당신은심장질환이있어운동을시작할경우, 주치의와상의하도록안내를받은적이있습니까? 당신은운동을할때가슴통증을느낀적이있습니까? 당신은지난몇달동안운동을하지않았는데도가슴통증을느낀적이있습니까? 당신은정신을잃거나현기증때문에균형을잃은적이있습니까? 당신은최근뼈나관절에문제가있습니까? 당신은현재혈압또는심장문제로의사가처방한약을복용하고있습니까? 운동을할수없는그밖의이유가있습니까? 미국스포츠의학회 건강관련신체체력평가메뉴얼

운동검사가필요한경우 심장운동부하검사 연령 >35세관상동맥질환이의심되거나진단받은경우 15년이상된 1형당뇨병환자 10년이상된 2형당뇨병환자미세혈관합병증, 말초혈관질환자율신경병증

운동계획세우기 운동종류를선택하여 ( 질병, 선호도, 기타요건고려 ) 일주일에약 700kcal~2000kcal 에너지소모하도록 횟수는적어도 3 회이상실시하도록

운동시간 주당 150 분이상 (= 700kcal 이상 ) 주 3 회 주 4 회 주 5 회 50 분씩 40 분씩 30 분씩 개인체력고려! 최소 10 분씩 3 번 = 한번에 30 분

운동강도 [1] 심박수계산법 [( 최대심박수-안정시심박수 ) * 0.5~0.75] + 안정시심박수최대심박수 =220-나이안정시심박수 = 1분심박수자율신경장애, 심혈관계질환자는사용하지못함.

운동강도 [2] 자각인지법 운동효과미비 옆사람과대화가가능한약간숨차게 상해위험, 질병악화 강도분류매우가볍다가볍다약간힘들다힘들다매우힘들다

운동전, 후 준비운동 / 정리운동 스트레칭체조약 5~10분정도실시합니다. 8~10초정도유지, 3회반복호흡유지

근력운동방법 어깨, 허리, 가슴, 복부, 다리근육운동 큰근육먼저-> 작은근육 ( 가슴-> 팔 ) 8~12회반복하는것은 2~3회실시 반복횟수사이휴식시간 30초 ~1분 지속적으로호흡을유지하는것이중요

팔근력운동방법

어깨근력운동방법

배근력운동방법

허벅지근력운동방법

종아리근력운동방법

결론 운동과 PA 는대사증후군을감소시키는데효과가있다 AT, RT 모두근육, 지방에서의인슐린저항성개선, 여러대사증후군인자들의향상에효과가있다. 운동은교육을통해이루어져야한다.