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Exercise in DiabetesExercise in Diabetes
Exercise in Diabetes Mellitus
Dr Shahjada SelimDr Shahjada SelimDepartment of EndocrinologyDepartment of Endocrinology
Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical UniversityEmailEmail : :[email protected]
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DefinitionsDefinitions
Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state.
Exercise in DiabetesExercise in Diabetes
Physical Activity
Caspersen, et al., Public health Rep,1985
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DefinitionsDefinitions
Exercise in DiabetesExercise in Diabetes
A set of attributes that people have or achieve, which relates to the ability to perform physical activity.
Caspersen, et al., Public health Rep,1985
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Physical Fitness
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DefinitionsDefinitions
The amount of energy expended during exercise relative to the energy expenditure during rest.
Exercise in DiabetesExercise in Diabetes
Metabolic Equivalent (MET)
Energy expenditure during rest = 1 MET = 3.5 ml of O2 / kg. min = 1 kcal / kg. hr
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DIABETES MANAGEMENT “TRIAD”
Medication
Nutrition
EXERCISE
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Classification of Exercise
Aerobic exercise: Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc…
Exercise in DiabetesExercise in Diabetes
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Classification of Exercise Classification of Exercise
Exercise in DiabetesExercise in Diabetes
Strength (Resistance) exercise: Weight training with free weight,
machine, elastic rope, calisthenics, etc…
Flexibility exercise: Stretching exercise.
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Physical Activity Intensity in MET
Light: Less than 3 MET
Exercise in DiabetesExercise in Diabetes
Moderate: 3 – 6 MET
Vigorous: Above 6 MET
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Moderate & Vigorous IntensityModerate & Vigorous Intensity Physical Activities Physical Activities
Exercise in DiabetesExercise in Diabetes
Moderate: Brisk walking, Recreational swimming,
Volleyball, Slow aerobics, Moderate cycling Gardening, Tennis-double, Badminton etc..
Vigorous: Jogging, Running, Tennis-single, Basketball,
Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Soccer, etc
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Exercise in DiabetesExercise in Diabetes
What is the Amount of Physical ActivityWhat is the Amount of Physical Activity that Promotes Health?that Promotes Health?
Moderate Intensity Physical Activity. Energy Expenditure = 3 - 6 MET That is: ≥ 30 min/day, ≥ 5 days/week. 150 min. per week. ACSM, 2000; CDC, 1996
≥ 1000 k. calories/week. Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000
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Exercise in DiabetesExercise in Diabetes
Exercise Exercise & & DiabetesDiabetes
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Exercise in DiabetesExercise in Diabetes
Can Exercise PreventCan Exercise Prevent or or Delay DiabetesDelay Diabetes ??
Evidences fromEvidences from Randomized Clinical TrialsRandomized Clinical Trials
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Malmo Study
Sweden
260 males(6 yrs)
Eriksson & Lindgarde,Eriksson & Lindgarde, Diabetologia, Diabetologia, 1999119991
Da Qing, China China 577 males & Females (6 yrs)
Pan, et al,Pan, et al, Diabetes Care, Diabetes Care, 19971997
The Nurse’s Health Study
USA 70,000Nurses (8 yrs)
Hu, et alHu, et al,.,. JAMA, JAMA, 19991999
Finnish Experimental Study
Finland 523 males& Females (4 yrs)
Tuomilehto, et al.,Tuomilehto, et al., N N Engl J Med, Engl J Med, 20012001
Diabetes Prevention Study
USA 3234 males & Females (3 yrs)
Diabetes Prev. Program Diabetes Prev. Program Research GroupResearch Group,, N Engl J Med, N Engl J Med, 20022002
Exercise in Exercise in DiabetesDiabetes
Exercise in the Prevention of DiabetesExercise in the Prevention of Diabetes
Participants are either normal or have Participants are either normal or have ++ GTT GTT
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Exercise in DiabetesExercise in Diabetes
Moderate Physical Activity Moderate Physical Activity Performed Regularly for 120 – 200 Performed Regularly for 120 – 200
min. per week reduces the min. per week reduces the Incidence of diabetes in People Incidence of diabetes in People
Predisposed to DiabetesPredisposed to Diabetes..
Exercise in the Prevention of diabetesExercise in the Prevention of diabetesSummary of the ResultsSummary of the Results
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Exercise in DiabetesExercise in Diabetes
Exercise Exercise in the in the Management of Management of
DiabetesDiabetes
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Exercise in DiabetesExercise in Diabetes
Exercise & Type 1 DiabetesExercise & Type 1 Diabetes
Improves physical fitness.Improves physical fitness.
Increases self confidence.Increases self confidence. Improves CV function & CHD risk profile.Improves CV function & CHD risk profile. It has no direct effect on glucose control.It has no direct effect on glucose control. Proper timing of Exercise & Insulin.Proper timing of Exercise & Insulin.
Avoid strenuous exercise before bed time. Avoid strenuous exercise before bed time.
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Exercise in DiabetesExercise in Diabetes
Exercise & Type 2 DiabetesExercise & Type 2 Diabetes
Improves physical fitness & reduces fat %.Improves physical fitness & reduces fat %.
Increases self confidence.Increases self confidence.
Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.
Improves glucose control:Improves glucose control: Improving insulin sensitivity.Improving insulin sensitivity. Increasing Glu T4Increasing Glu T4 (glucose transporters).(glucose transporters).
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0
5
10
15
20
0 30 60 90 120 150 180
Before After
Exercise in Exercise in DiabetesDiabetes
Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 DiabeticsP
lasm
a G
luco
seP
lasm
a G
luco
se (m
mol
/l)(m
mol
/l)
Time Time (min)(min)
12 months of Training12 months of Training
Holloszy, et al. Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-65 1986, 711: 55-65
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0
400
800
1200
1600
0 30 60 90 120 150 180
Before After
Exercise in Exercise in DiabetesDiabetes
Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 DiabeticsP
lasm
a In
sulin
Pla
sma
Insu
lin (p
mol
/l)(p
mol
/l)
Time Time (min)(min)
12 months of Training12 months of Training
Holloszy, et al. Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-65 1986, 711: 55-65
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Exercise in DiabetesExercise in Diabetes
Exercise Prescription for Diabetic
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Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 1/41/4
Aerobic activity for 30 Aerobic activity for 30 min.min. extended extended (gradually)(gradually) to 60 to 60 min.min. every day or most days/week/ 150 every day or most days/week/ 150 mins per wk.mins per wk.HR during activity should be gradually HR during activity should be gradually increased to reach 60 – 70% of HR max.increased to reach 60 – 70% of HR max.
Exercise session should include 5-10 min. of Exercise session should include 5-10 min. of warm-up and a 5 min of cool-down.warm-up and a 5 min of cool-down.
Exercise must involve most major muscles in Exercise must involve most major muscles in both lower and upper parts of the body.both lower and upper parts of the body.
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Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 2/42/4
Moderate intensity weight training program Moderate intensity weight training program is recommended to maintain muscle strength is recommended to maintain muscle strength
( 8-12 repetitions 2 times /week).( 8-12 repetitions 2 times /week).
Exercise must be regular. Benefits are Exercise must be regular. Benefits are diminished after 1 -2 weeks of stopping .diminished after 1 -2 weeks of stopping .
For those with feet problems, avoid running.For those with feet problems, avoid running. Alternate between walking, swimming, and cycling.Alternate between walking, swimming, and cycling.
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Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 3/43/4
When using insulin, avoid exercise if glucose When using insulin, avoid exercise if glucose levels below 100 mg/dl or above 250 mg/dl.levels below 100 mg/dl or above 250 mg/dl.
Use proper shoes, with silica gel or air-filled Use proper shoes, with silica gel or air-filled soles, and always keep feet dry. soles, and always keep feet dry.
Avoid dehydration by keeping your body Avoid dehydration by keeping your body always hydratedalways hydrated..
Do not inject insulin into a body part that is Do not inject insulin into a body part that is expected to be used during exercise.expected to be used during exercise.
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Exercise in DiabetesExercise in Diabetes
Graded Exercise Testing for DiabeticGraded Exercise Testing for Diabetic 4/44/4
It is recommended before any moderate to It is recommended before any moderate to high intensity exercise, especially if:high intensity exercise, especially if: Age is > 35 yrs.Age is > 35 yrs. Type 2 diabetes for > 10 yrs duration.Type 2 diabetes for > 10 yrs duration. Type 1 diabetes for > 15 yrs duration.Type 1 diabetes for > 15 yrs duration. Presence of any CHD risk factors.Presence of any CHD risk factors. Presence of microvascular diseasePresence of microvascular disease (retinopathy, nephropathy).(retinopathy, nephropathy). Presence of peripheral vascular disease.Presence of peripheral vascular disease.
ADA Position Statement, Diabetes Care, 2002ADA Position Statement, Diabetes Care, 2002May 3, 2023May 3, 2023 2525
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Exercise in DiabetesExercise in Diabetes
Exercise Exercise Prescription for Prescription for Special Cases Special Cases
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Exercise in DiabetesExercise in Diabetes
Diabetic with Diabetic with Peripheral NeuropathyPeripheral Neuropathy
Repetitive exercise on insensitive feet can Repetitive exercise on insensitive feet can lead to ulceration & fractureslead to ulceration & fractures..
Peripheral neuropathy may results in loss Peripheral neuropathy may results in loss of sensation in the feet.of sensation in the feet.
Limit weight-bearing exerciseLimit weight-bearing exercise (Treadmill, (Treadmill, Prolonged walking, Jogging, Step exercise, etc..) Prolonged walking, Jogging, Step exercise, etc..)
Use proper shoes, and always monitor the feetUse proper shoes, and always monitor the feet..
Alternative exercises areAlternative exercises are: Swimming, : Swimming, Bicycling, Arm exercise, Chair exercise, etc..Bicycling, Arm exercise, Chair exercise, etc..
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Exercise in DiabetesExercise in Diabetes
Diabetic with Diabetic with Autonomic NeuropathyAutonomic Neuropathy
Hypotension and hypertension are more Hypotension and hypertension are more likely to develop after vigorous exercise.likely to develop after vigorous exercise.
This condition may limit exercise capacity & This condition may limit exercise capacity & increase the risk of CV event during exercise.increase the risk of CV event during exercise.
Those patients may have difficulty with Those patients may have difficulty with thermoregulation:thermoregulation: Avoid exercise in hot or cold environments.Avoid exercise in hot or cold environments. encourage adequate hydration. encourage adequate hydration.
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Hypoglycemia during or after ExerciseHypoglycemia during or after Exercise
It will most likely occur if the patient: Takes insulin or diabetes pill. Skips a meal. Exercises for a long time. Exercises strenuously.
Exercise in DiabetesExercise in Diabetes
If it occurs, what can be done? Patient must eat a snack before exercise, or. Adjusts the medication dose. Remember: Patient should always carry a source
of CHO with him ( An apple or orange juice, or a piece of fruit).
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Exercise in DiabetesExercise in Diabetes
Energy ExpenditureEnergy Expenditureduring during
Physical Activity!Physical Activity!
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ActivityActivity CaloreiCalorei Brisk walking Brisk walking 0.070.07 RunningRunning (7.5 min per km) (7.5 min per km) 0.130.13 RunningRunning (5 min per km)(5 min per km) 0.2080.208 SwimmingSwimming 0.1620.162 Rope skippingRope skipping (70/min)(70/min) 0.1620.162 Rope skippingRope skipping (80/min)(80/min) 0.1650.165 BadmintonBadminton 0.0970.097 TennisTennis 0.1090.109
SquashSquash 0.2120.212 BasketballBasketball 0.1380.138
Energy Cost of Physical ActivityEnergy Cost of Physical Activity))kilocalorie/kg. minkilocalorie/kg. min((
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ActivityActivity METMETWalking Walking (slow)(slow) 2.52.5Walking (Walking (Brisk)Brisk) 44
RunningRunning (7.5 min per km) (7.5 min per km) 88 SwimmingSwimming 66 Rope skippingRope skipping (slow)(slow) 88 Weight trainingWeight training 66 BadmintonBadminton 4.54.5 Tennis Tennis (single)(single) 88
SquashSquash 1212 BasketballBasketball 88
Energy Cost of Physical ActivityEnergy Cost of Physical Activity))METMET((
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Exercise in DiabetesExercise in Diabetes
How to Calculate How to Calculate Energy Expenditure Energy Expenditure during Brisk Walkingduring Brisk Walking!!
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Exercise in DiabetesExercise in Diabetes
== 0.07 0.07 k.k. caloriecalorie per kg of body weightper kg of body weight //
min.min.
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
An Example:An Example: a a person weighing 76 kg would expend:person weighing 76 kg would expend: 0.070.07 X 76 = X 76 = 5.35.3 k. k. calorie per min.calorie per min.
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Exercise in DiabetesExercise in Diabetes
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
If he has to expend 1200 k.If he has to expend 1200 k. calories per week.calories per week. How much time he should walk per week?How much time he should walk per week?
1200 / 5.3 = 226.4 min.1200 / 5.3 = 226.4 min. = 45 min / 5 days per week, or= 45 min / 5 days per week, or = 57 min / 4 days per week.= 57 min / 4 days per week.
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Preparing For Exercise
Proper warm-up consisting of 5–10 min of aerobic activity
Activity session 15- 30 mins
cool-down should be structured similarly to the warm-up and should last about 5–10 min
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Types of Physical Activity
The Mnemonic: “SAFE” exercises are recommended:
Strengthening exercises Aerobic exercises Flexibility exercises Endurance exercises
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Aerobic exercise
With Oxygen Aerobic exercise is the type
that moves large muscle groups and causes you to breathe more deeply and your heart to work harder to pump blood. It's also called cardiovascular exercise. It improves the health of your heart and lungs.
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Anaerobic (Resistance) Exercise
Anaerobic exercise uses large muscles that do not require oxygen for short periods of exercise. It helps build strong muscles; lowers blood glucose makes the action of insulin more effective.
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Flexibility (Stretching) Exercise Flexibility exercises
are aimed at increasing or maintaining range of motion at joints, also improve tone in muscles and keep it supple. They develop better muscular and body control.
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Endurance Exercises
Low Resistance, High Repetition Exercises
Examples: Walking, cycling,
swimming, or upper extremity ergometry that involve the use of the large muscle of the body.
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How much exercise?
Exercises should be done according to FITT principle. FREQUENCY: Exercising 4 to 6 times a week. INTENSITY: 30-40 min of exercise at 50- 60 % of
target heart rate. TYPE: SAFE exercises are recommended. TIME: Morning is ideal
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A SAMPLE WALKING PROGRAM
Warm Up Target Zone Exercising Cool Down Time Total
Week 1
Session A Walk normally 5 min. Then walk briskly 5 min. Then walk normally 5 min. 15 min.
Session B --Repeat above pattern--
Session C --Repeat above pattern--
Continue with at least three exercise sessions during each week of the program. If you find a particular week's pattern tiring, repeat it before going on to the next pattern. You do not have to complete the walking program in 12 weeks.
Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min.
Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min.
Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min.
Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min.
Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min.
Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min.
Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min.
Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min.
Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min.
Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min.
Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min.
Week 13 and thereafter:Check your pulse periodically to see if you are exercising within your target zone. As you get more in shape, try exercising within the upper range of your target zone. Gradually increase your brisk walking time to 30 to 60 minutes, three or four times a week.
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Breathing Exercises
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Neck Exercises
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Hand Exercises
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Trunk Exercises
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Trunk Exercises…………
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Leg Exercises
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Peripheral and autonomic neuropathy
Recommendednon-weight-
bearing activities
swimmingbicyclingchair and arm
exercises
Contraindicated treadmillprolonged
walking joggingstep exercises
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Nephropathy
RecommendedLow to
moderate intensity forms of exercise
ContraindicatedHigh intensity
forms of exercise
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Diabetic retinopathy
Recommended Low-impact
cardiovascular conditioning, such as swimming, walking, low-impact aerobics, stationary cycling, endurance exercises
Contraindicated Strenuous activities,
pounding or jarring, such as weight lifting, jogging, high-impact aerobics, racquet sports.
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Hypoglycemia Management
The person should be instructed to stop exercising. People at risk for hypoglycemia should always carry a source of glucose with them such as glucose tablets, candy or juice in order to treat hypoglycemia.
Remember- it is a medical emergency
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Snacking to prevent hypoglycemia
Basic Rules: Snack prior to activity to prevent hypoglycemia
Adjust quantity based on pre-activity BG or direction of BG
BG low or dropping: usual carbs BG OK or stable: usual carbs BG High or rising: usual carbs
Snack at least once per hour during prolonged activity
Choose high-glycemic forms of carbohydrate
Source: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
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Useful Tips For Exercise Always carry an
identification card with you
Check your feet before you walk
Choose good footwear, light clothing
Drink lots of water
Don’t exercise during hot seasons, and when not feeling well
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What Can Physical Activity Do For You?
Give you more energy
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What Can Physical Activity Do For You?
Help you lose weight and keep it off
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What Can Physical Activity Do For You?Increase
flexibility and strength
Slow bone lossProvide better
quality of life
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What Can Physical Activity Do For You?
Build muscle
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What Can Physical Activity Do For You?
Improve your sex life
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What Can Physical Activity Do For You?
Lift your mood
Treat depression
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What Can Physical Activity Do For You?
Reduce stress and anxiety
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What Can Physical Activity Do For You?
Improve blood glucose control
(lowers A1C)
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Physical activity lowers blood glucose in type 2 diabetes by helping:
muscle cells become more sensitive to insulin keep the liver from producing too much glucose build more muscle you lose weight and keep it off
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What Can Physical Activity Do For You?
Keep your heart healthy
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Physical activity helps your heart by:
Strengthening heart muscle Lowering resting heart rate Lowering blood pressure Improving cholesterol Reducing risk of heart attack and stroke
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“Sitting” through life increases your risk of:
heart disease high blood pressure high cholesterol overweight type 2 diabetes
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We now must plan physical activity into our schedule
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Getting Started
Check with your doctor if you: Are over age 35 Have had diabetes more than 10
years Have high blood pressure, heart
disease, poor circulation, or other diabetes complications
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Aerobic Activity Walking briskly Dancing Bicycling Hiking Jogging/running Skating Stair climbing Swimming Water exercise
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Resistance Activities
“Push, Pull, and Lift” Activities increase muscle strength prevent falls increase mobility improve blood glucose control
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Stretching
Improves your balance and coordination
Makes you more flexible Reduces stiffness Reduces your risk of injury
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How Can You Begin?
Choose activity (example: brisk walking)
Set a long-term goal - at least 30 minutes a day, 3-5 days a week
Buy comfortable walking shoes Get a partner
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Physical Activity Is Like Magic for Type 2
Diabetes
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