Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation

Q: What are the key findings of this study?

Insulin resistance and type 2 diabetes had a 67% combined prevalence in cardiac rehabilitation patients, and all glycemic groups reduced weight and increased METs.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Coronary heart disease enrolled in cardiac rehabilitation (n=818). Intervention: Insulin resistance (HbA1c 5.7% to <6.5%) or Type 2 Diabetes Mellitus (HbA1c ≥6.5%) during cardiac rehabilitation vs. Normal HbA1c / No insulin resistance (HbA1c <5.7%). Primary outcome: Combined prevalence of insulin resistance and type 2 diabetes mellitus at baseline and changes in body weight and maximal metabolic equivalents (METs) after cardiac rehabilitation (p=<0.05).

Q: What does this research mean for the field?

Insulin resistance and type 2 diabetes mellitus affect two-thirds of patients entering contemporary cardiac rehabilitation, and while all glycemic groups achieve significant improvements in weight and functional capacity, patients without insulin resistance achieve greater improvements than those with diabetes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To determine the prevalence of insulin resistance and type 2 diabetes mellitus in contemporary cardiac rehabilitation and compare clinical responses across patient subgroups.

Sherrie Khadanga; Patrick D. Savage; Philip A. Ades

doi:10.1097/hcr.0000000000000187

May 14, 2016Journal of Cardiopulmonary Rehabilitation and PreventionOpen Access

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation

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Key result

Cardiac rehabilitation improves weight and METs across glycemic groups despite a ~67% baseline dysglycemia prevalence.

P<0.05
n=818

Why the study?

What is the prevalence of insulin resistance and type 2 diabetes mellitus in contemporary cardiac rehabilitation, and how do clinical responses in weight and exercise capacity compare across glycemic subsets of patients with coronary heart disease?

Key Points

To determine the prevalence of insulin resistance and type 2 diabetes mellitus in contemporary cardiac rehabilitation and compare clinical responses across patient subgroups.
Cohort study of 818 patients with coronary heart disease enrolled in cardiac rehabilitation, categorized by baseline HbA1c into normal (NoIR: <5.7%), insulin resistant (IR: ≥5.7% to <6.5%), and type 2 diabetes (T2DM: ≥6.5%).
Assessed changes in body weight, body mass index, and exercise capacity using maximal metabolic equivalents (METs) and peak VO2 across 488 patients who completed the program, including a 4-session behavioral weight-loss intervention in 95 participants.
The combined prevalence of IR (44%) and T2DM (23%) was 67%, closely tracking metabolic syndrome prevalence (65%); women had higher rates of IR (73% vs 64%) and metabolic syndrome (72% vs 63%) than men (all P < .05).
Body weight decreased across all groups (NoIR: -2.3 ± 4.0 kg; IR: -1.7 ± 4.0 kg; T2DM: -1.0 ± 4.2 kg) and maximal METs increased (NoIR: +2.2 ± 2.5; IR: +2.1 ± 2.8; T2DM: +1.3 ± 2.3) (all P < .05), with NoIR achieving greater improvements than T2DM (P < .05).
Participants in the behavioral weight-loss program achieved significantly greater weight loss than nonparticipants (-5.6 ± 3.5 kg vs -1.0 ± 3.8 kg, P < .0001).

Study Design

Type

Cohort (n=818)

Multicenter

No

Structured PICO

What is the prevalence of insulin resistance and type 2 diabetes mellitus in contemporary cardiac rehabilitation, and how do clinical responses in weight and exercise capacity compare across glycemic subsets of patients with coronary heart disease?

P

Population

818 consecutive patients (27% female) with established coronary heart disease enrolled in a 3-to-4-month single-center US cardiac rehabilitation program following a recent coronary event.

E

Exposure

Cardiac rehabilitation exercise training program (up to 3 sessions/week for 45-60 minutes over 3-4 months, maximum 36 sessions, plus 2 classroom diet sessions and optional 4-session behavioral weight loss program for overweight patients), stratified by baseline glycemic status: Insulin Resistance (IR: HbA1c ≥5.7% to <6.5% or fasting glucose ≥100 mg/dL) and Type 2 Diabetes Mellitus (T2DM: HbA1c ≥6.5% or fasting glucose ≥126 mg/dL).

C

Comparator

Patients with normal HbA1c / no insulin resistance (NoIR: HbA1c <5.7%) undergoing the same cardiac rehabilitation program.

O

Outcome

Prevalence of insulin resistance (IR), type 2 diabetes mellitus (T2DM), and metabolic syndrome (MetSyn) at baseline, and pre- to post-rehabilitation clinical responses in body weight, BMI, and maximal metabolic equivalents (peak METs) at 3-4 months.surrogate

Main Result

Absolute Event Rate: 67% vs 33.7%

p-value: p=<0.05

Limitations

Predominantly Caucasian study cohort at a single center
Lack of information regarding dose and type of T2DM medication
Lack of follow-up HbA1c levels for individuals who completed cardiac rehabilitation
Use of dyslipidemia medications at entry likely underestimated the prevalence of metabolic syndrome
Use of fasting blood glucose and HbA1c is less precise than the gold standard hyperinsulinemic-euglycemic clamp technique
Predominantly Caucasian cohort at a single center
Lack of follow-up HbA1c levels for individuals who completed CR
Use of dyslipidemia medications at entry to CR likely resulted in an underestimation of MetSyn prevalence
Inclusion of HbA1c criterion for hyperglycemia differs from standard ATP III guidelines, and FBG/HbA1c are less precise than the hyperinsulinemic-euglycemic clamp technique

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Implication

Two-thirds (67%) of patients entering contemporary cardiac rehabilitation have insulin resistance or type 2 diabetes, underscoring the necessity of integrating structured behavioral weight loss with exercise training to optimize metabolic and functional outcomes.

Abstract

PURPOSE: The goal of this study was to determine the prevalence of insulin resistance (IR) and type 2 diabetes mellitus (T2DM) in contemporary cardiac rehabilitation (CR) and to compare clinical responses in CR between these subsets of patients with coronary heart disease (CHD). METHODS: The study cohort included 818 patients enrolled in CR and separated into 3 groups: (1) individuals with normal hemoglobin A1c (HbA1c) (NoIR: HbA1c < 5.7%); (2) individuals with IR (IR: HbA1c ≥ 5.7 to <6.5%); (3) and individuals with T2DM (HbA1c ≥ 6.5%). RESULTS: The combined prevalence of IR (44%) and T2DM (23%) was 67%, which paralleled the prevalence of metabolic syndrome (MetSyn), present in 65% of patients. Women had a higher prevalence of IR and MetSyn than men (73% vs 64%, 72% vs. 63%, respectively) and a greater percentage with an elevated waist circumference (71% vs 60%) (all P < .05). All 3 groups experienced decreases in body weight (NoIR = -2.3 ± 4.0, IR = -1.7 ± 4.0, T2DM = -1.0 ± 4.2 kg) and increases in maximal metabolic equivalents (METs) at exercise testing (NoIR = +2.2 ± 2.5 vs IR = +2.1 ± 2.8 vs T2DM = +1.3 ± 2.3) (all P < .05). Individuals with NoIR achieved greater improvements in weight, body mass index, and METs than patients with T2DM (all P < .05). Selected individuals who participated in a 4-session behavioral weight-loss program lost more than twice the weight as nonparticipants. CONCLUSIONS: The combined prevalence of IR and T2DM in patients with CHD enrolled in CR was remarkably high (67%). To reverse the deleterious consequences of IR and T2DM, targeted interventions involving exercise and weight loss need to be a central focus of CR programming.

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Cite This Study

Khadanga et al. (2016) conducted a cohort in Coronary heart disease enrolled in cardiac rehabilitation (n=818). Insulin resistance (HbA1c 5.7% to <6.5%) or Type 2 Diabetes Mellitus (HbA1c ≥6.5%) during cardiac rehabilitation vs. Normal HbA1c / No insulin resistance (HbA1c <5.7%) was evaluated on Combined prevalence of insulin resistance and type 2 diabetes mellitus at baseline and changes in body weight and maximal metabolic equivalents (METs) after cardiac rehabilitation (p=<0.05). Insulin resistance and type 2 diabetes had a 67% combined prevalence in cardiac rehabilitation patients, and all glycemic groups reduced weight and increased METs.

synapsesocial.com/papers/6a7c79c13f411608c626c796 https://doi.org/10.1097/hcr.0000000000000187

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Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Insulin Resistance and Diabetes Mellitus in Contemporary Cardiac Rehabilitation

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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