The role of exercise combined with tocilizumab in visceral and epicardial adipose tissue and gastric emptying rate in abdominally obese participants: protocol for a randomised controlled trial.

BACKGROUND: Exercise reduces the amount of visceral adipose tissue (VAT) and the risk of cardiometabolic diseases. The underlying mechanisms responsible for these exercise-induced adaptations are unclear, but they may involve lipolytic actions of interleukin-6 (IL-6). Contracting skeletal muscles secrete IL-6, leading to increased circulating IL-6 levels in response to exercise. The aim of this study is to investigate whether IL-6 is involved in mediating the effects of exercise on visceral and epicardial adipose tissue volume and glycaemic control. METHODS/DESIGN: Seventy-five physically inactive males and females aged > 18 years with a waist-to-height ratio > 0.5 and/or waist circumference ≥ 88 cm (females) or ≥ 102 cm (males) are being recruited to participate in a 12-week intervention study. Participants are randomly allocated to one of five groups (1:1:1:1:1). Two groups consist of supervised endurance exercise training combined with the IL-6 blocker tocilizumab (ET) or saline used as placebo (EP), two groups consist of no exercise combined with tocilizumab (NT) or placebo (NP), and one group consists of resistance exercise and placebo (RP). Although the study is an exploratory trial, the primary outcome is change in VAT volume from before to after intervention, with secondary outcomes being changes in (1) epicardial adipose tissue, (2) pericardial adipose tissue and (3) gastric emptying. Depots of adipose tissue are quantitated by magnetic resonance imaging Gastric emptying and glucose metabolism are assessed using mixed-meal tolerance tests. DISCUSSION: Understanding the role of IL-6 in mediating the effects of exercise on visceral and epicardial adipose tissue and glycaemic control may lead to novel therapeutic approaches in the prevention of cardiometabolic diseases. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02901496 . Registered on 1 August 2016 and posted retrospectively on 15 September 2016.

Effect of an Intensive Lifestyle Intervention on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial.

Importance: It is unclear whether a lifestyle intervention can maintain glycemic control in patients with type 2 diabetes. Objective: To test whether an intensive lifestyle intervention results in equivalent glycemic control compared with standard care and, secondarily, leads to a reduction in glucose-lowering medication in participants with type 2 diabetes. Design, Setting, and Participants: Randomized, assessor-blinded, single-center study within Region Zealand and the Capital Region of Denmark (April 2015-August 2016). Ninety-eight adult participants with non-insulin-dependent type 2 diabetes who were diagnosed for less than 10 years were included. Participants were randomly assigned (2:1; stratified by sex) to the lifestyle group (n = 64) or the standard care group (n = 34). Interventions: All participants received standard care with individual counseling and standardized, blinded, target-driven medical therapy. Additionally, the lifestyle intervention included 5 to 6 weekly aerobic training sessions (duration 30-60 minutes), of which 2 to 3 sessions were combined with resistance training. The lifestyle participants received dietary plans aiming for a body mass index of 25 or less. Participants were followed up for 12 months. Main Outcomes and Measures: Primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 12-month follow-up, and equivalence was prespecified by a CI margin of ±0.4% based on the intention-to-treat population. Superiority analysis was performed on the secondary outcome reductions in glucose-lowering medication. Results: Among 98 randomized participants (mean age, 54.6 years [SD, 8.9]; women, 47 [48%]; mean baseline HbA1c, 6.7%), 93 participants completed the trial. From baseline to 12-month follow-up, the mean HbA1c level changed from 6.65% to 6.34% in the lifestyle group and from 6.74% to 6.66% in the standard care group (mean between-group difference in change of -0.26% [95% CI, -0.52% to -0.01%]), not meeting the criteria for equivalence (P = .15). Reduction in glucose-lowering medications occurred in 47 participants (73.5%) in the lifestyle group and 9 participants (26.4%) in the standard care group (difference, 47.1 percentage points [95% CI, 28.6-65.3]). There were 32 adverse events (most commonly musculoskeletal pain or discomfort and mild hypoglycemia) in the lifestyle group and 5 in the standard care group. Conclusions and Relevance: Among adults with type 2 diabetes diagnosed for less than 10 years, a lifestyle intervention compared with standard care resulted in a change in glycemic control that did not reach the criterion for equivalence, but was in a direction consistent with benefit. Further research is needed to assess superiority, as well as generalizability and durability of findings. Trial Registration: clinicaltrials.gov Identifier: NCT02417012.

Effect of endurance versus resistance training on quadriceps muscle dysfunction in COPD: a pilot study.

INTRODUCTION: Exercise is an important countermeasure to limb muscle dysfunction in COPD. The two major training modalities in COPD rehabilitation, endurance training (ET) and resistance training (RT), may both be efficient in improving muscle strength, exercise capacity, and health-related quality of life, but the effects on quadriceps muscle characteristics have not been thoroughly described. METHODS: Thirty COPD patients (forced expiratory volume in 1 second: 56% of predicted, standard deviation [SD] 14) were randomized to 8 weeks of ET or RT. Vastus lateralis muscle biopsies were obtained before and after the training intervention to assess muscle morphology and metabolic and angiogenic factors. Symptom burden, exercise capacity (6-minute walking and cycle ergometer tests), and vascular function were also assessed. RESULTS: Both training modalities improved symptom burden and exercise capacity with no difference between the two groups. The mean (SD) proportion of glycolytic type IIa muscle fibers was reduced after ET (from 48% [SD 11] to 42% [SD 10], P<0.05), whereas there was no significant change in muscle fiber distribution with RT. There was no effect of either training modality on muscle capillarization, angiogenic factors, or vascular function. After ET the muscle protein content of phosphofructokinase was reduced (P<0.05) and the citrate synthase content tended increase (P=0.08) but no change was observed after RT. CONCLUSION: Although both ET and RT improve symptoms and exercise capacity, ET induces a more oxidative quadriceps muscle phenotype, counteracting muscle dysfunction in COPD.

Head-to-head comparison of intensive lifestyle intervention (U-TURN) versus conventional multifactorial care in patients with type 2 diabetes: protocol and rationale for an assessor-blinded, parallel group and randomised trial.

INTRODUCTION: Current pharmacological therapies in patients with type 2 diabetes (T2D) are challenged by lack of sustainability and borderline firm evidence of real long-term health benefits. Accordingly, lifestyle intervention remains the corner stone in the management of T2D. However, there is a lack of knowledge regarding the optimal intervention programmes in T2D ensuring both compliance as well as long-term health outcomes. Our objective is to assess the effects of an intensive lifestyle intervention (the U-TURN intervention) on glycaemic control in patients with T2D. Our hypothesis is that intensive lifestyle changes are equally effective as standard diabetes care, including pharmacological treatment in maintaining glycaemic control (ie, glycated haemoglobin (HbA1c)) in patients with T2D. Furthermore, we expect that intensive lifestyle changes will decrease the need for antidiabetic medications. METHODS AND ANALYSIS: The study is an assessor-blinded, parallel group and a 1-year randomised trial. The primary outcome is change in glycaemic control (HbA1c), with the key secondary outcome being reductions in antidiabetic medication. Participants will be patients with T2D (T2D duration <10 years) without complications who are randomised into an intensive lifestyle intervention (U-TURN) or a standard care intervention in a 2:1 fashion. Both groups will be exposed to the same standardised, blinded, target-driven pharmacological treatment and can thus maintain, increase, reduce or discontinue the pharmacological treatment. The decision is based on the standardised algorithm. The U-TURN intervention consists of increased training and basal physical activity level, and an antidiabetic diet including an intended weight loss. The standard care group as well as the U-TURN group is offered individual diabetes management counselling on top of the pharmacological treatment. ETHICS AND DISSEMINATION: This study has been approved by the Scientific Ethical Committee at the Capital Region of Denmark (H-1-2014-114). Positive, negative or inconclusive findings will be disseminated in peer-reviewed journals, at national and international conferences. TRIAL REGISTRATION NUMBER: NCT02417012.

Comparison of the Danish step test and the watt-max test for estimation of maximal oxygen uptake: the Health2008 study.

INTRODUCTION: There is a need for simple and feasible methods for estimation of cardiorespiratory fitness (CRF) in large study populations, as existing methods for valid estimation of maximal oxygen consumption are generally time consuming and relatively expensive to administer. The Danish step test may be a feasible alternative for estimation of VO2max. AIM: To compare a simple fitness test, the Danish step test, to an indirect maximal test, the watt-max test, for estimation of VO2max. METHODS: In the population-based Health2008 study, 2218 men and women aged 30-60 years were invited. Altogether, 795 eligible participants (response rate 35.8%) performed the watt max and the Danish step test. Correlation and agreement between the two VO2max test results was explored by Pearson's rho, Bland-Altman plots, Kappa(w), and gamma coefficients. RESULTS: The correlation between VO2max (ml/kg/min) estimated by the two tests was moderate to high (men: r = 0.69, p < 0.0001; women: r = 0.77, p < 0.0001). The Danish step test slightly overestimated VO2max compared to the watt-max test, more so in women than in men. Agreement between the two tests when VO2max was classified in five levels was gamma = 0.77, Kappa(w )= 0.42 in women, and gamma = 0.64, Kappa(w )= 0.37 in men. CONCLUSION: The Danish step test is a safe and feasible alternative to the more time-consuming watt-max test as a method for estimation of VO2max in large adult population-based studies.

Strength training increases insulin-mediated glucose uptake, GLUT4 content, and insulin signaling in skeletal muscle in patients with type 2 diabetes.

Strength training represents an alternative to endurance training for patients with type 2 diabetes. Little is known about the effect on insulin action and key proteins in skeletal muscle, and the necessary volume of strength training is unknown. A total of 10 type 2 diabetic subjects and 7 healthy men (control subjects) strength-trained one leg three times per week for 6 weeks while the other leg remained untrained. Each session lasted no more than 30 min. After strength training, muscle biopsies were obtained, and an isoglycemic-hyperinsulinemic clamp combined with arterio-femoral venous catheterization of both legs was carried out. In general, qualitatively similar responses were obtained in both groups. During the clamp, leg blood flow was higher (P < 0.05) in trained versus untrained legs, but despite this, arterio-venous extraction glucose did not decrease in trained legs. Thus, leg glucose clearance was increased in trained legs (P < 0.05) and more than explained by increases in muscle mass. Strength training increased protein content of GLUT4, insulin receptor, protein kinase B-alpha/beta, glycogen synthase (GS), and GS total activity. In conclusion, we found that strength training for 30 min three times per week increases insulin action in skeletal muscle in both groups. The adaptation is attributable to local contraction-mediated mechanisms involving key proteins in the insulin signaling cascade.

Does the aging skeletal muscle maintain its endocrine function?

Contracting skeletal muscles produce and release the cytokine interleukin (IL)-6 and this release is augmented by the presence of low muscle glycogen. Since muscle metabolism in elderly subjects relies on glycogen more than younger subjects, it is possible that aging is associated with an altered production of muscle-derived IL-6 during exercise. To test the relation between aging and muscle-derived IL-6, seven healthy elderly males, mean age 70+/-1 (SEM) yr and six healthy young males, mean age 26+/-2 (SEM) yr performed three hours of dynamic knee-extensor exercise at 50% of maximal work load (Wmax). IL-6 mRNA and glycogen in muscles were analysed and the IL-6 release were estimated before, during and after the exercise. Although the absolute work load in the elderly was less than half of that in the young, 41.1+/-3.1 W and 92.5+/-4.0 W, respectively, the muscle glycogen utilization after three hours of exercise did not differ between groups, 238.7+/-52.4 and 245.2+/-74.0 mmol/kg muscle in elderly and young, respectively. This could explain that the IL-6 release and the IL-6 mRNA amplification increased during exercise with no difference between groups, two-way ANOVA-P = 0.50 and 0.45, respectively. In conclusion, elderly healthy people maintain the capacity to produce and release IL-6 in response to dynamic exercise, with no difference compared to young individuals furthermore, glycogen utilization expressed in changes of glycogen related to muscle mass was equal in elderly and young subject at 50 % of Wmax.

Feasibility, physical capacity, and health benefits of a multidimensional exercise program for cancer patients undergoing chemotherapy.

Cancer patients frequently experience considerable loss of physical capacity and general wellbeing when diagnosed and treated for their disease. The aim of this study was to evaluate the feasibility, physical capacity, and health benefits of a multidimensional exercise program for cancer patients during advanced stages of disease who are undergoing adjuvant or high-dose chemotherapy. The supervised program included high- and low-intensity activities (physical exercise, relaxation, massage, and body-awareness training). A total of 23 patients between 18 and 65 years of age (median 40 years) participated in groups of seven to nine patients for 9 h weekly for 6 weeks. Physical capacity in terms of repetition maximum (RM) and maximal oxygen uptake (VO(2)max), physical activity level and psychosocial wellbeing (EORTC QLQ-C30, SF-36, HAD) were compared prior to and after completion of the program. The program was safe and well tolerated. The completion rate was 85.2%. Highly significant increases in physical capacity (1RM, VO(2)max) and an improved level of physical activity were achieved. Quality of life and general wellbeing assessments indicated improvements in several measures, but without reaching significance. It is concluded that an exercise program, which combines high- and low-intensity physical activities, may be used to prevent and/or minimize physical inactivity, fatigue, muscle wasting and energy loss in cancer patients undergoing chemotherapy.

Skiing across the Greenland icecap: divergent effects on limb muscle adaptations and substrate oxidation.

This study investigates the adaptive response of the lower limb muscles and substrate oxidation during submaximal arm or leg exercise after a crossing of the Greenland icecap on cross-country skies. Before and after the 42-day expedition, four male subjects performed cycle ergometer and arm-cranking exercise on two separate days. On each occasion, the subjects exercised at two submaximal loads (arm exercise, 45 W and 100 W; leg exercise, 100 W and 200 W). In addition, peak oxygen uptake ((VO(2max))) was determined for both leg and arm exercise. Before and after the crossing, a muscle biopsy was obtained from the vastus lateralis and the triceps brachii muscles prior to exercise (N=3). After the crossing, body mass decreased by 5.7+/-0.5 kg (in four of four subjects), whereas (VO(2max)) was unchanged in the arm (3.1+/-0.2 l min(-1)) and leg (4.0+/-0.1 l min(-1)). Before the crossing, respiratory exchange ratio (RER) values were 0.84+/-0.02 and 0.96+/-0.02 during submaximal arm exercise and 0.82+/-0.02 and 0.91+/-0.01 during submaximal leg exercise at the low and high workloads, respectively. After the crossing, RER was lower (in three of four subjects) during arm exercise (0.74+/-0.02 and 0.81+/-0.01) but was higher (in three of four subjects) during leg exercise (0.92+/-0.02 and 0.96+/-0.01) at the low and high workloads, respectively. Citrate synthase and beta-hydroxy-acyl-CoA-dehydrogenase activity was decreased by approximately 29% in vastus lateralis muscle and was unchanged in triceps brachii muscle. Fat oxidation during submaximal arm exercise was enhanced without a concomitant increase in the oxidative capacity of the triceps brachii muscle after the crossing. This contrasted with decreased fat oxidation during leg exercise, which occurred parallel to a decreased oxidative capacity in vastus lateralis muscle. Although the number of subjects is limited, these results imply that the adaptation pattern after long-term, prolonged, low-intensity, whole body exercise may vary dramatically among muscles.