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Table 1.  
Physical Characteristics of All Participants and Subgroups Who Completed Heat Acclimation
Physical Characteristics of All Participants and Subgroups Who Completed Heat Acclimation
Table 2.  
Peak Responses in Patients With and Without Type 2 Diabetes During Exercise Before and After Heat Acclimationa
Peak Responses in Patients With and Without Type 2 Diabetes During Exercise Before and After Heat Acclimationa
1.
McGinn  R, Poirier  MP, Louie  JC,  et al.  Increasing age is a major risk factor for susceptibility to heat stress during physical activity.  Appl Physiol Nutr Metab. 2017;42(11):1232-1235. doi:10.1139/apnm-2017-0322PubMedGoogle ScholarCrossref
2.
Kenny  GP, Sigal  RJ, McGinn  R.  Body temperature regulation in diabetes.  Temperature (Austin). 2016;3(1):119-145. doi:10.1080/23328940.2015.1131506PubMedGoogle ScholarCrossref
3.
Poirier  MP, Gagnon  D, Friesen  BJ, Hardcastle  SG, Kenny  GP.  Whole-body heat exchange during heat acclimation and its decay.  Med Sci Sports Exerc. 2015;47(2):390-400. doi:10.1249/MSS.0000000000000401PubMedGoogle ScholarCrossref
4.
Kenny  GP, Notley  SR, Gagnon  D.  Direct calorimetry: a brief historical review of its use in the study of human metabolism and thermoregulation.  Eur J Appl Physiol. 2017;117(9):1765-1785. doi:10.1007/s00421-017-3670-5PubMedGoogle ScholarCrossref
5.
American Diabetes Association.  5. Lifestyle Management: Standards of Medical Care in Diabetes-2019.  Diabetes Care. 2019;42(suppl 1):S46-S60. doi:10.2337/dc19-S005PubMedGoogle ScholarCrossref
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Research Letter
October 8, 2019

Exercise Heat Stress in Patients With and Without Type 2 Diabetes

Author Affiliations
  • 1Human and Environmental Physiology Research Unit, University of Ottawa, Ottawa, Ontario, Canada
  • 2Department of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 3FAME Laboratory, University of Thessaly, Trikala, Greece
  • 4Faculty of Health and Sport Sciences, University of Tsukuba, Tsukuba City, Japan
JAMA. 2019;322(14):1409-1411. doi:10.1001/jama.2019.10943

Performing exercise in the heat can increase the risk of health complications, especially among middle-aged and older adults who have impaired whole-body heat loss (WBHL) relative to young adults.1 That risk may be higher among patients with type 2 diabetes due to abnormalities in cutaneous vasodilation and sweating, which facilitate WBHL.2 However, repeated brief exercise for 7 days or more during heat exposure (heat acclimation) may mitigate this risk by enhancing WBHL.3 We therefore assessed whether type 2 diabetes impairs heat loss in physically active middle-aged and older adults during exercise heat stress and whether heat acclimation could offset any impairment.

Methods

Following written informed consent, physically active men who performed 150 or more minutes per week of moderate exercise; were aged 50 through 70 years; lived in the Ottawa, Ontario, Canada, region; and had or did not have type 2 diabetes volunteered for the study, which was approved by the University of Ottawa Ethics Board and ran from April 2014 to May 2018. Only patients with well-controlled type 2 diabetes who had been diagnosed for 5 years or longer, had hemoglobin A1c concentrations that ranged from 5.5% to 9.0%, and had no diabetes-related complications were included. Participants completed three 30-minute bouts of cycling at increasing metabolic heat productions (150, 200, or 250 W/m2) in dry heat (40°C, 15% relative humidity) within a direct air calorimeter (a device to precisely measure WBHL).4 Participants were invited to repeat this protocol after a 7-day heat acclimation involving exercise (50% of V̇o2peak [peak aerobic power]) for 90 minutes per day in similar conditions.3

Rates (W/m2) of WBHL (dry + evaporative heat loss) and body heat storage (metabolic heat production) as well as heart rate (expressed as percent heart rate reserve) were measured continuously and expressed as peak responses (mean of the final 5 minutes of exercise at the highest metabolic heat production [250 W/m2]). The change in body heat storage (kJ) was used to derive the change in mean body temperature.4 Data were compared between groups using unpaired t tests and within each group using paired t tests (α = .05 [2-tailed]; Prism 8, GraphPad).

Results

Of the 34 participants, 17 had type 2 diabetes and 17 did not. Of the 34 participants, 8 with and 10 without type 2 diabetes completed heat acclimation. No statistically significant between-group differences in physical characteristics were observed (Table 1). Overall, peak WBHL was statistically significantly lower in patients with type 2 diabetes (187 W/m2) vs those without (215 W/m2) (difference, −28 W/m2; 95% CI, −46 to −10 W/m2; P = .003), due to reduced evaporative heat loss (Table 2). Peak body heat storage, mean body temperature change, and heart rate reserve were statistically significantly greater in patients with type 2 diabetes than in those without (Table 2).

In participants completing heat acclimation, peak WBHL was statistically significantly lower in patients with type 2 diabetes (197 W/m2) vs those without (225 W/m2) (difference, −28 W/m2; −44 to −11 W/m2; P = .002; Table 2) before heat acclimation. Following heat acclimation, however, there was a statistically significant increase in peak WBHL in both subgroups (Table 2), with the magnitude of that improvement being statistically significantly greater in patients with type 2 diabetes (28 W/m2) vs those without (11 W/m2), for a difference of 17 W/m2 (95% CI, 2 to 32 W/m2; P = .03). Subsequently, no statistically significant between-group differences in other outcomes were observed following heat acclimation (Table 2).

Discussion

Relative to healthy counterparts, physically active middle-aged and older men with well-controlled type 2 diabetes had attenuated heat-loss capacity during exercise in the heat, due primarily to impaired sweat evaporation, which exacerbated thermal (body temperature) and cardiovascular (heart rate) strain. These preliminary findings indicate that exercise heat stress may pose a health concern in patients with type 2 diabetes, especially because physical activity is recommended for diabetes management.5 However, participants with type 2 diabetes demonstrated a greater improvement in heat-loss capacity than did healthy controls after heat acclimation. A randomized clinical trial of repeated brief, supervised exercise is warranted to determine whether heat acclimation during heat exposure offsets diabetes-related thermoregulatory impairments and health complications. Study limitations include the small sample size, the inclusion of only men and patients with well-controlled diabetes, and the specific exercise and environmental conditions.

Section Editor: Jody W. Zylke, MD, Deputy Editor.
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Article Information

Accepted for Publication: July 8, 2019.

Corresponding Author: Glen P. Kenny, PhD, School of Human Kinetics, University of Ottawa, 125 University, Room 367, Montpetit Hall, Ottawa, ON K1N 6N5, Canada (gkenny@uottawa.ca).

Author Contributions: Dr Kenny had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sigal, Flouris, Kenny.

Acquisition, analysis, or interpretation of data: Notley, Poirier, D’Souza, Fujii, Kenny.

Drafting of the manuscript: Notley, Kenny.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Notley.

Obtained funding: Sigal, Flouris, Kenny.

Administrative, technical, or material support: Kenny.

Supervision: Poirier, Sigal, Kenny.

Conflict of Interest Disclosures: Dr Kenny reported receiving grants from the Canadian Institutes of Health Research. No other disclosures were reported.

Funding/Support: This project was supported by grants 286363 and 399434 from the Canadian Institutes of Health Research.

Role of the Funder/Sponsor: The Canadian Institutes of Health Research had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank Pierre Boulay, PhD, Université de Sherbrooke, Faculté des Sciences de l’Activité Physique, for providing technical assistance and Steve Doucette, MSc, Community Health and Epidemiology, Dalhousie University, for providing statistical advice. No compensation was provided for their roles.

References
1.
McGinn  R, Poirier  MP, Louie  JC,  et al.  Increasing age is a major risk factor for susceptibility to heat stress during physical activity.  Appl Physiol Nutr Metab. 2017;42(11):1232-1235. doi:10.1139/apnm-2017-0322PubMedGoogle ScholarCrossref
2.
Kenny  GP, Sigal  RJ, McGinn  R.  Body temperature regulation in diabetes.  Temperature (Austin). 2016;3(1):119-145. doi:10.1080/23328940.2015.1131506PubMedGoogle ScholarCrossref
3.
Poirier  MP, Gagnon  D, Friesen  BJ, Hardcastle  SG, Kenny  GP.  Whole-body heat exchange during heat acclimation and its decay.  Med Sci Sports Exerc. 2015;47(2):390-400. doi:10.1249/MSS.0000000000000401PubMedGoogle ScholarCrossref
4.
Kenny  GP, Notley  SR, Gagnon  D.  Direct calorimetry: a brief historical review of its use in the study of human metabolism and thermoregulation.  Eur J Appl Physiol. 2017;117(9):1765-1785. doi:10.1007/s00421-017-3670-5PubMedGoogle ScholarCrossref
5.
American Diabetes Association.  5. Lifestyle Management: Standards of Medical Care in Diabetes-2019.  Diabetes Care. 2019;42(suppl 1):S46-S60. doi:10.2337/dc19-S005PubMedGoogle ScholarCrossref
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