Gretchen Reynolds: You are never too old to give up on exercise

cyclist robert marchand

At the age of 105, the French amateur cyclist and world-record holder Robert Marchand is more aerobically fit than most 50-year-olds — and appears to be getting even fitter as he ages, according to a revelatory new study of his physiology.

The study, which appeared in December in The Journal of Applied Physiology, may help to rewrite scientific expectations of how our bodies age and what is possible for any of us athletically, no matter how old we are.

Many people first heard of Mr. Marchand last month, when he set a world record in one-hour cycling, an event in which someone rides as many miles as possible on an indoor track in 60 minutes.

Mr. Marchand pedaled more than 14 miles, setting a global benchmark for cyclists age 105 and older. That classification had to be created specifically to accommodate him. No one his age previously had attempted the record.

She was particularly interested in Mr. Marchand’s workout program and whether altering it might augment his endurance and increase his speed.

Conventional wisdom in exercise science suggests that it is very difficult to significantly add to aerobic fitness after middle age. In general, VO2 max, a measure of how well our bodies can use oxygen and the most widely accepted scientific indicator of fitness, begins to decline after about age 50, even if we frequently exercise.

But Dr. Billat had found that if older athletes exercised intensely, they could increase their VO2 max. She had never tested this method on a centenarian, however.

But Mr. Marchand was amenable. A diminutive 5 feet in height and weighing about 115 pounds, he said he had not exercised regularly during most of his working life as a truck driver, gardener, firefighter and lumberjack. But since his retirement, he had begun cycling most days of the week, either on an indoor trainer or the roads near his home in suburban Paris.

Almost all of this mileage was completed at a relatively leisurely pace.

Dr. Billat upended that routine. But first, she and her colleagues brought Mr. Marchand into the university’s human performance lab.

They tested his VO2 max, heart rate and other aspects of cardiorespiratory fitness. All were healthy and well above average for someone of his age. He also required no medications.

He then went out and set the one-hour world record for people 100 years and older, covering about 14 miles.

Afterward, Dr. Billat had him begin a new training regimen. Under this program, about 80 percent of his weekly workouts were performed at an easy intensity, the equivalent of a 12 or less on a scale of 1 to 20, with 20 being almost unbearably strenuous according to Mr. Marchand’s judgment. He did not use a heart rate monitor.

The other 20 percent of his workouts were performed at a difficult intensity of 15 or above on the same scale. For these, he was instructed to increase his pedaling frequency to between 70 and 90 revolutions per minute, compared to about 60 r.p.m. during the easy rides. (A cycling computer supplied this information.) The rides rarely lasted more than an hour.

Mr. Marchand followed this program for two years. Then he attempted to best his own one-hour track world record.

First, however, Dr. Billat and her colleagues remeasured all of the physiological markers they had tested two years before.

Mr. Marchand’s VO2 max was now about 13 percent higher than it had been before, she found, and comparable to the aerobic capacity of a healthy, average 50-year-old. He also had added to his pedaling power, increasing that measure by nearly 40 percent.

Unsurprisingly, his cycling performance subsequently also improved considerably. During his ensuing world record attempt, he pedaled for almost 17 miles, about three miles farther than he had covered during his first, record-setting ride.

He was 103 years old.

These data strongly suggest that “we can improve VO2 max and performance at every age,” Dr. Billat says.

There are caveats, though. Mr. Marchand may be sui generis, with some lucky constellation of genes that have allowed him to live past 100 without debilities and to respond to training as robustly he does.

Lifestyle may also matter. Mr. Marchand is “very optimistic and sociable,” Dr. Billat says, “with many friends,” and numerous studies suggest that strong social ties are linked to a longer life. His diet is also simple, focusing on yogurt, soup, cheese, chicken and a glass of red wine at dinner.

But for those of us who hope to age well, his example is inspiring and, Dr. Billat says, still incomplete. Disappointed with last month’s record-setting ride, he believes that he can improve his mileage, she says, and may try again, perhaps when he is 106.

Diabetic children miss out on hospital checks

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Paediatric endocrinology clinics have a  non-attendance rate of 11.4% in the south west of the UK. The majority of these patients have diabetes.

Children who did not attend were more likely to  come  from families living in areas of high deprivation and to have a child protection alert in their hospital records.

In 60% of the cases, the GP was not informed that the child had not appeared, so they were not in a position to follow the child up themselves. Some of the children were sent other appointments, some were given an open attendance appointment and some were discharged.

About half of the children were eventually seen within a year and a third attended A and E. Almost a quarter went back to see the GP and half of these were re-referred.

My comments: In my own practice I am aware that a minority of parents are very poor at attending diabetic clinics with their children. We are always informed and keep out an eye for opportunistic intervention when the child attends for another matter. Our hospital has a good nurse liaison service and they do their best to keep a dialogue open with the parents and visit at home. Sometimes lack of money for bus fares is given as an issue. Sometimes work commitments or having to make arrangements to look after other children in the family is the reason. For one reason or another, the child’s diabetes management does not have the priority that it is given in other homes, and that doesn’t work out well on the long term.

Reported in BMJ 24th June 2017 by Ingrid Torjesen BMJ 2017;357:j2983

 

Whistle while you work

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Physical exercise improves your sense of wellbeing but different intensities give different results.

Healthy adults were tested after doing various types of exercises and activities and compared how they felt.

Office work and driving a car were considered light intensity and were associated with  an improved mood.

Housework or walking  were considered moderate activities and not only improved mood but reduced pain, in those that suffered this.

Doing nothing reduced people’s moods.

Journal of Health Psychology doi:10.1177/1359105317691589

Adapted from article in Human Givens Vol 1 2017

Smoking rates down in young adults

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Smoking decreased in all age groups in England between 2010 and 2016.  Overall 15.5% of the population smoke compared to 19.9%.

The greatest reduction was seen in young adults in the 18-24 age group, down from 26% to 19%.

Men are more likely to smoke, 19% than women, 14% but those who are unemployed are almost twice as likely to smoke compared to those who have jobs. 16% v 30%.

My comment: Diabetes and smoking is particularly hazardous long term. Unfortunately General Practitioners are reporting that smoking cessation schemes are losing funding due to budget cuts. If you don’t smoke, please don’t start. 

If you do smoke and think that you’ll never find the motivation to give it up, there are some people who managed it, who discuss what was important to them in the videos in this link:

 

https://www.cdc.gov/tobacco/campaign/tips/resources/videos/index.html?s_cid=OSH_tips_D9390

 

Keep safe when cycling

cyclist

Reflective jackets are a great safety aid for cyclists riding in the dark, if they have them and  wear them consistently. A possible way to overcome a cyclists reluctance to wear the said jacket, say for example if they think to themselves, “I’ll be back before it gets dark or it’s too warm for my jacket” is to take the decision out of the equation.

Researchers have found that reflective tape attached to the rear frame of the bike and pedal cranks does the job of increasing visibility just as well as jackets do, but without any active behaviour required of the cyclist.

“Reflective tape is highly recommended to complement front and back lights in bicycle riding at night”, they conclude.

Human Factors, 2016, doi:10.177/001872081667145

Adapted from article in Human Givens Volume 24 No 1 2017

How does blood sugar control compare between pump users and insulin injecting adults?

insulin pump

If adults get the same level of education about blood sugar management there is only a tiny improvement in blood sugar control with a pump compared to a basal bolus injection regime.

The REPOSE trial was based in the UK with 315 participants across eight sites. Using small groups the patients were taught the DAFNE course, Dose Adjustment for Normal Eating. After the course the patients were randomised to either multiple daily injections which is standard UK management, or insulin pump use.

The organisers wanted to see how many people managed to get their hba1c below 7.5% after two years and what effects the regimes had on quality of life and hypoglycaemia.

Out of the original 315 patients, 260 finished the courses and entered the trial. There were small improvements in both groups for hba1c. The pump group got a 0.85% improvement in hba1c and the injectors got 0.42% improvement. This was not considered to be good enough to recommend pump provision, which is more expensive than pen injectors, to adults as a routine measure.

The pump group started with hba1s averaging around 9.5% and ended up around 8.7%. The injectors started with an average of 9.0% and ended up around 8.5%.  In addition there was no particular difference in hypoglycaemia or psychosocial outcomes.

My comment: It is a pity that DAFNE is considered the gold standard educational tool for type one diabetics when the outcomes are so underwhelming. The main problems are that although carb counting is included, carbohydrate restriction is not.  Insulin coverage of protein is not done and the seven unit rule is ignored. These are the main reasons that the outcomes are so poor. Structured education in person is expensive and time consuming for health care professionals. Why not grasp the nettle and actually teach people what they need to know to get normal blood sugars and not hba1cs of 8.5-8.7 which are certain to lead to diabetic complications?

Based on BMJ article BMJ 2017;356:j1285

Study Finds Some Type 1s DO Produce Insulin

Free stock photo of health, medical, medicine, prickAn article in Medical New Today caught our eye this week – research recently found that people with type 1 diabetes produced some insulin.

Yeah, yeah, I thought, it’s the newbies again. But apparently not. The Uppsala University in Sweden’s researchers found that nearly half of patients who’d had the condition for more than ten years did produce insulin.

Type 1 diabetes is routinely described as a condition where the body doesn’t make insulin. The researchers found that the insulin-producing patients had higher levels of immune cells that produce a protein called interleukin-35 (IL-35). This is believed to suppress the immune system and reduce inflammation in the body.

The findings were reported by the study’s co-author, Dr Daniel Epses, in Diabetes Care.

Type 1 diabetes happens when the immune system mistakenly attacks insulin-producing cells or beta cells in the pancreas.

This was believed to lead to a complete loss of insulin production in type 1 diabetics, but studies in recent years have shown that some patients still have functioning beta cells.

Dr Epses and his colleagues wanted to work out if there are any immunological mechanisms that could explain why some type 1 diabetics still produce small amounts of insulin.

The study looked at 113 patients aged 18 and over. All of them had been living with diabetes for at least ten years.

Researchers measured the levels of C-peptide in the blood – an indicator of insulin production. They also measured circulating cytokine levels, including IL-35. Cytokines are proteins that are secreted by the immune cells and they play a major role in cell signalling.

The team found that almost half the patients were C-peptide positive – in other words, they had some level of insulin production. The results also showed that patients who were C-peptide positive had significantly higher levels of IL-35 in their blood, compared with the patients who were C-peptide negative (the ones who had lost all insulin production).

Previous research has indicated that IL-35 can suppress auto-immune disease. It is possible that in some type 1 diabetics, the protein prevents the immune system from attacking and destroying beta cells.

Dr Epses and his colleagues, who are based at the Department of Medical Cell Biology at Uppsala University, couldn’t determine if C-peptide positive patients had higher IL-35 levels at type 1 diabetes diagnosis, or whether levels of the protein increased over time because of a reduced immune system attack on insulin-producing beta cells.

More study is needed to gain an understanding of how IL-35 might relate to insulin production. The researchers believe, however, that their findings show the potential of IL-35 as a treatment for type 1 diabetes. As the findings also show that almost half of patients with type 1 diabetes produce some insulin, the team thinks it might be possible to encourage regeneration of their remaining beta cells and so boost insulin production.

 

 

What’s new in the prevention of the microvascular complications of diabetes?

Apart from blood sugar control what’s new in the prevention of the microvascular complications of diabetes?

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Retinopathy

At diagnosis, 10.5% of type two diabetics already have retinopathy. New research has shown that severe proliferative diabetic neuropathy can be predicted by measuring the size of retinal blood vessels, but this is still being developed in research centres. It could become a part of the usual screening process in the future.

Lowering blood pressure in those who are hypertensive by at least 10 points, can reduce the onset of retinopathy but does not affect the rate at which it develops into proliferative retinopathy. What does seem to work is the use of oral Fenofibrate.

Laser photocoagulation reduces the rate of progression of proliferative retinopathy and the onset of severe visual loss. Direct injection of drugs that inhibit Vascular Endothelial Growth Factor such as pegaptanib, ranibizumab, and bevacizumab also help but they are less freely available, due to cost.

dialysis

Nephropathy

NICE recommend spot urinary albumin to the creatinine ratio and glomerular filtration rate on diagnosis and then yearly. If the rate is raised on 2 out of 3 samples within six months then nephropathy is confirmed and the severity graded.

Blood pressure targets are 140/90 for those without nephropathy and 130/80 for those that have it. Some people may benefit from lower blood pressure targets of 120 systolic such as Asian, Hispanic and African American populations.

Both ACE inhibitors and Sartans (ARB) reduce nephropathy and ACE inhibitors also improve all- cause mortality.  These drugs are the first choice for most diabetics when prescribing anti-hypertensives.

Early referral to a nephrologist showed an improvement in interventions and mortality rates. There was also a small improvement in kidney function when the new drug Dapagliflozin was used.

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Neuropathy

There are other causes of neuropathy that may need to be considered before diabetic neuropathy is diagnosed. These are: alcohol, chemotherapy, vitamin B12 deficiency, hypothyroidism, renal disease, paraneoplastic syndromes due to eg multiple myeloma and bronchogenic carcinoma, HIV infection, chronic inflammatory demyelinating neuropathy, inherited neuropathies and vasculitis.

A new Japanese drug Epalrestat improved diabetic neuropathy but did not improve autonomic neuropathy.

There was insufficient evidence to show that exercise, pulse infrared light therapy, education about foot ulceration and complex interventions such as combining patient education, podiatry care, foot ulceration assessment, motivational coaching to provide self- care, worked or not.

 

BMJ 4th February 2017 Willy Marcos Valencia and Hermez Florez from Miami Florida.

 BMJ 2017;356:i6505

Planning a pregnancy: the importance of getting slim before you get started

newborn baby

In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Obesity raises the risk of cancer

cancer

Obesity is strongly associated with eleven different cancers.

These are: oesophageal, multiple myeloma, stomach, colon, rectum, biliary tract, pancreas, breast, endometrium, ovary and kidney.  For many cancers there seems to be a dose response.

This was found by Kyrgiou and colleagues by studying over 95 meta-analyses from various sources.

The BMJ reports, “The unavoidable conclusion is that preventing excess adult weight gain can reduce the risk of cancer. Furthermore, emerging evidence suggests that excess body fat in early life also has an adverse effect on the risk of cancer in adulthood. Clinicians, particularly those in primary care, can be a powerful force to lower the burden of obesity related cancers, as well as the many other chronic diseases linked to obesity such as diabetes, heart disease and stroke. The data are clear. The time for action is now.”

As a GP, I don’t really think that I am a “powerful force” that can turn the obesity epidemic round. It is amazing what faith the authors Yikyung Park and Graham Colditz have regarding our abilities.

 

Adapted from Adiposity and cancer at major anatomical sites BMJ 2017; 356:j477 and BMJ 2017;356:j908