The participants will perform moderate intensity exercise at heart rate corresponding with 50%WMAX (determined during maximal workload test) under mild normobaric hypoxia (FiO2: 15%), two times 30 minutes per day for 4 consecutive days on a cycle ergometer. 24h glucose concentration will be monitored continuously. Afterwards, a meal test challenge will be performed at day 5 to determine fasting/postprandial substrate oxidation.

The participants will perform moderate intensity exercise at 50% WMAX (determined during maximal workload test) under normoxia (FiO2: 21%) two times 30 minutes per day for 4 consecutive days on a cycle ergometer. 24h glucose concentration will be monitored continuously. Afterwards, a meal test challenge test will be performed at day 5 to determine fasting/postprandial substrate oxidation.

Obesity

Insulin Resistance

Impaired Glucose Tolerance in Obese

The participant will perform the exercise interventions consisting of cycling at the heart rate corresponding with 50%WMAX (normoxia) or heart rate corresponding with 50% WMAX (hypoxia) for 30 minutes, twice a day, for 4 consecutive days. 24h glucose concentration will be monitored continuously.

Moderate intensity exercise under mild normobaric hypoxia and normoxia

Department of Human Biology, Maastricht University Medical Centre

Hypoxic Exercise and Glucose Metabolism

Exercise During Mild Hypoxia Exposure to Reverse Impaired Glucose Metabolism in Overweight and Obese Humans

Glucose concentration will be measured in the interstitial fluid of the subcutaneous adipose tissue every 5 min using a glucose sensor (Enlite Glucose Sensor MiniMed; Medtronic) (iPro2 Professional CGM MiniMed; Medtronic, Northridge, CA, USA), which will be inserted subcutaneously, at 5 cm from the umbilicus, on the right side of the abdomen, and will be connected to a continuous glucose monitor (iPro2 Professional CGM MiniMed; Medtronic, Northridge, CA, USA). The cumulative effects of the 4 day exercise regimens will be determined using the average 24h glucose levels collected on day 4.

Moderate intensity exercise under mild hypoxia compared to normoxia. The cumulative effects of the 4 day exercise regimens will be determined using the 24h glucose levels collected on day 4. Glycemic variability, which reflects acute glucose fluctuations, will be assessed by the standard deviation of the average 24 h glucose concentration (SD)

Moderate intensity exercise under mild hypoxia compared to normoxia. The cumulative effects of the 4 day exercise regimens will be determined using the 24h glucose levels collected on day 4 frequency and duration of hypo- and hyperinsulinemia will be monitored using the iPro2 device and Enlite Glucose Sensor (Medtronic) and is defined as a glucose level of ≥10.0 mmol/l for hyperglycemia, whilst hypoglycemia will be defined as a glucose concentration ≤3.9 mmol/l.

Moderate intensity exercise under mild hypoxia compared to normoxia. Energy expenditure will be determined by means of indirect calorimetry at day 5 (under normoxia in both periods), after 4 consecutive days of performing exercise under normoxia or mild hypoxia.

Moderate intensity exercise under mild hypoxia compared to normoxia. Substrate oxidation (e.g. carbohydrate and fat oxidation) will be determined by means of indirect calorimetry at day 5 (under normoxia in both periods), after 4 consecutive days of performing exercise under normoxia or mild hypoxia.

Moderate intensity exercise under mild hypoxia compared to normoxia. Every morning, before having breakfast, systolic and diastolic blood pressure will be monitored in mmHg.

Moderate intensity exercise under mild hypoxia compared to normoxia. HOMA-IR will be determined from circulating insulin and glucose levels at sampled at day 5.

Moderate intensity exercise under mild hypoxia compared to normoxia. Skeletal muscle biopsy will be performed at day 5 under fasting conditions and will be analysed for histology and gene/protein expression. Gene expression will be performed by targeted q-PCR (quantitative-polymerase chain reaction), and protein expression will be performed by means of Western blotting to quantify expression of AMPK.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting blood will be sampled and analysed for systemic inflammatory markers by means of ELISA

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating glucose concentrations (mmol/L) will be determined during a high-carbohydrate mixed-meal test.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating insulin concentrations (mU/L) will be determined during a high-carbohydrate mixed-meal test.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating free fatty acids concentrations (μmol/L) will be determined during a high-carbohydrate mixed-meal test.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating glycerol (μmol/L) will be determined during a high-carbohydrate mixed-meal test.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating triglycerides (μmol/L) will be determined during a high-carbohydrate mixed-meal test.

Moderate intensity exercise under mild hypoxia compared to normoxia. At day 5, fasting and postprandial circulating lactate (mmol/L) will be determined during a high-carbohydrate mixed-meal test.

Maastricht University Medical Center

Anesthesia care providers who receive monthly feedback emails on the participants specific quality measures

Anesthesia care providers who did NOT receive monthly feedback emails on the participants specific quality measures

Postoperative Morbidity

If the provider received an email about the participants performance metrics

Receive metric feedback email

Quality improvement initiative for Multicenter Perioperative Outcomes Group

The Multicenter Perioperative Outcomes Group (MPOG) was formed in 2008 to develop the necessary policies, procedures, and technical infrastructure required for multicenter perioperative outcomes research

Investigating Trends in Compliance With Quality Assurance Metrics

Investigating improved bundle compliance for all providers where all anesthesia care providers at the given institution were randomized to receive emails (attending/residents/CRNAs).

Investigating improved bundle compliance for all providers where only one anesthesia care provider group at the given institution were randomized to receive emails (attending/residents/CRNAs).

For all providers at baseline that already met bundle threshold compliance, we will investigate to determine if improved their performance during the study period.

Investigating improved bundle compliance for all providers expect those in the coordinating center to determine if they performance metrics have improved.

Determine if patient postoperative morbidity are affected by a provider receiving metric emails for all cases,

Determine if patient postoperative morbidity are affected by a provider receiving metric emails but only for CRNAs, fellows and anesthesiology residents.

Determine if patient postoperative morbidity are affected by a provider receiving metric emails for cases done outside the coordinating center.

Nirav Shah

Assistant Professor

University of Michigan

The patients with severe OSA (AHI>=30) who do not fulfill the specific exclusion criteria wil be randomized. In the CPAP and diet arm, patients wil receive Continuous Positive air pressure therapy and the regular dietary treatment.

The diet arm wil receive the Conventional diet treatment that usually receive the patients included in the Bariatric Surgery Program

Metabolic Syndrome

Adipokines

Cytokines

Treatment with Continuous Positive Airway Pressure

CPAP

Conventional diet treatment that undergo patients in the Bariatric Surgery Program

alpha glucose/hypoxia

Hypoxic Exercise and Glucose Metabolism

Investigating Trends in Compliance With Quality Assurance Metrics

Impact of Obstructive Sleep Apnea Syndrome on Metabolic Syndrome in Severe Obesity

המאגר השלם ביותר של צמחי מרפא המגובה על ידי המדע