up
EXERCISE
Guidelines.
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A Regular exercise programme, tailor made for every
individual and undertaken after due fitness evaluation, with
regular monitoring, is an essential part of modern diabetes
management!
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Regular exercise
confers benefits not only on glycemic (sugar) control, but also on
insulin sensitivity, lipid abnormalities, cardiovascular
system, physical fitness, psychological well being, optimizing
body weight and disease prevention.
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It is however being
increasingly recognized, that exercise programme carried out
without adequate precautions, do carry some risks as well.
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These risks can be
minimized with pre-exercise screening, individualized exercise
programme prescription, careful monitoring and patient
education.
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Pre-exercise evaluation.
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All patients should
undergo a complete history and examination to identify
cardiac, macro/micro vascular and neurological complications. The
extent of investigations would dependent on the risk level of
the patient and would need to be individualized.
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Exercise should not be
prescribed to patients with very high blood glucose, and those
in ketosis, unless treated adequately.
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Patients with
significantly retinopathy and renal dysfunction may also need
to undergo specific treatment before embarking on an exercise
programme.
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Patients with foot
infections should avoid exercise until adequately treated.
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Patients with
cardiovascular abnormalities should not undertake exercise
unless this is in close consultation with cardiologist.
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Other contraindications
to exercise as seen in non diabetics also apply to patients
with diabetes.
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Type of exercise.
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The exercise should be
aerobic and isotonic.
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Although the patient
may be allowed to choose his own form of exercise, walking
would appear to be the most appropriate, and safe, exercise
for most patients.
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Isometric exercises,
such as weight lifting, etc., are not recommended.
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Frequency and duration.
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The frequency should be
around 3-5 days a week, at the least.
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The duration of each
exercise session should be around 30-45 minutes, with a five
minute warm up and a five minute cooling off period. The
duration and frequency may be adjusted to individual needs.
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Intensity.
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The intensity of the
exercise needs to be individualized.
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Intensity is usually
measured in terms of the percentage of the patients maximum
heart rate (MHR). Initial exercise should be at a reduced
intensity which should be at a reduced intensity which should
then be increased to reach about 60-70% of the MHR. (MHR = 220
- age of the patient).
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Limiting the intensity
of the exercise such that the systolic blood pressure does not
exceed 180 mm Hg would seem prudent.
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Any patient undergoing
an exercise programme, who complains of any signs or symptoms
which would have contraindicated such a programme initially,
should discontinue the programme, and have a detailed
re-evaluation before restarting the exercise regimen.
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When the patient does
start the exercise programme again, the intensity should be
such as if the patient were beginning the exercise programme
anew. The exercise programme should never be restarted at the
intensity at which it was discontinued.
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An excellent parameter
to judge, is that the patient should be able to carry out a
normal conversation whilst exercising, without getting unduly
breathless.
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Special precautions.
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Correct footwear is
absolutely essential during exercise.
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The clothes worn by the
patient should be loose and comfortable.
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Feet should be
inspected daily and after an exercise schedule.
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Exercise during periods
of poor metabolic control (blood glucose more than 250% mg
and/or ketosis) should be avoided.
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Patients taking insulin
will need to modify their insulin dosages and diet; this is
true also for patients taking long acting sulfonylureas. (a class of anti-diabetic drugs)
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There is a risk for
developing hypoglycemia if extremely vigorous exercise is
carried out on an empty stomach. It would appear prudent to
take an extra snack of complex carbohydrates either, before or
immediately after any unexpected vigorous activity or exercise
in order to protect against hypoglycemia. If necessary an
additional snack in the mid activity, may also be advisable.
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It is not generally
widely known that the blood glucose lowering effect of any
vigorous exercise may last for sometime even after the
exercise/activity is completed. Thus, some patients may need
to modify their subsequent dose of insulin or OHA (oral
anti-diabetic medicines), and also
increase their food intake at the meal following the unduly
vigorous exercise/activity.
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Such diet and drug
modifications are usually required only whilst undertaking
unexpected and unduly vigorous forms of exercise of activity.
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Exercise
programme which are a part of one's regular
diabetes management plan would rarely need such modifications. |
Education.
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Patient education is the most important aspect in ensuring
patient compliance. The patient must understand the benefits that
can accrue from the exercise regimen, the potential hazards, the
precise manner of carrying out his exercise and, importantly, the
special precautions which he needs to take in order to get maximum
benefit without being exposed to potential risks.
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ACTIVITY |
Calories Spent
per minute
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Lying Down, Sleeping, Sitting
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1 to 1.25
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Standing, strolling (1 mile per hour)
playing cards, knitting, sewing, darning, desk work, car
driving, electric typing, using calculators, etc. (Note :
in many of these activities, the calories spent may
increase if the activity is associated with stress,
anxiety, anger etc)
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2 to 2.5
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Level walking (2 miles per hour ), level
bicycling (5m.p.h.) horseback riding (walding speed),
playing musical instruments like the piano, playing billiards
and snooker, golf using a power cart to move
around, manual typing, bartending, auto, TV and radio
repair
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2.5 to 4
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Walking at 3 mph, cycling at 6 mph,
Volleyball (6 man noncompetitive), horse riding (9 sitting
to trot), playing golf with lugging around the golf bag,
sailing (handling small boats), Badminton (social
doubles), cleaning windows, energetic musician.
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4 to 5
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Walking at 4 mph, cycling at 8 mph, Table
tennis, golf (carrying clubs), dancing (at a pace of a
dance like the foxtrot), Badminton (social singles),
tennis (social singles), tennis (social doubles), any calisthenics, painting walls, light carpentry
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5 to 6
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Walking at 4 mph, cycling at 10 mph, roller
skating, horse riding (trot), gardening (digging),
swimming (3/4 mph)
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6 to 7
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Walking at 5 mph, cycling at 11 mph,
Badminton (competitive), tennis (social singles), light
downhill skiing, water skiing
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7 to 8
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Jogging at 5 mph, cycling at 12 mph,
basketball, vigorous downhill skiing, carrying loads of
around 36 kgs
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8 to 10
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Running at .5.5 mph, cycling at 13 mph,
playing squash (social level), Handball (social level),
vigorous game of basketball.
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10 to 11
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What does exercise have to do with my diabetes?
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Exercise provides several benefits. Perhaps the most significant benefit to
diabetes is that it usually lowers blood sugar and helps your body better use
its food supply. Good diabetes control means keeping your blood-sugar level as
close as possible to normal (between 90 and 140 mg/dL). |
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Exercise may also help
insulin work better. |
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Exercise can lower cholesterol and triglyceride levels. |
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Exercise also improves the blood flow through small blood vessels, increases
the heart's ability to pump, helps burn excess calories, and relieves tension,
anxiety, and depression. |
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If you are overweight (9 out of 10 people with type II
diabetes are), an exercise diet plan can help you lose weight. |
Your health care provider is in the best position to help you decide when you
should exercise and what kind and how much exercise is best for you. Even after
you begin an exercise regimen, you should not exercise if your blood-sugar
control is poor. You and your doctor will reevaluate your exercise needs if you
develop retinopathy or blood vessel problems.
How do I begin exercising?
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The next step is to select an exercise regimen that would be fun for you. |
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Begin gradually and increase your work-out time. |
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Your goal will be to exercise a
minimum of 20 to 30 minutes and a maximum of 45 to 60 minutes at least 3 or 4
times per week. |
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Be consistent and exercise at the same time and same intensity
every day. |
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A good time to exercise is 15 to 30 minutes after a meal, when the
blood-sugar level is elevated. |
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Do not exercise strenuously in the late evening,
since your blood sugar continues to fall hours after completing your exercise. |
Besides consistency, what else should my exercise program contain?
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Every exercise program should have warm-up and a cool-down time to slowly
stretch and "warm up" the muscles and then to slowly decrease the
intensity and speed before stopping completely. |
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Never skip the warm-up
and cool-down periods. |
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Take your pulse before starting any exercise program and
retake your pulse before and after cool down. Your pulse should have increased
before cool down and decreased after it. Your doctor will help you determine
your target heart rates and show you how to take your pulse. |
Are there special precautions for people with insulin-dependent (type I)
diabetes?
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First, consult your doctor. Plan your activity to fit in with your meal plan
and with the action times and amounts of your insulin. |
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Avoid exercise when blood
sugar is consistently high and ketones are present in the urine. |
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Also, avoid
exercise at peak action time. For short-acting insulin, this peak action time
would be 2 to 4 hours after injection; for intermediate- acting insulin, this
would be 6 to 12 hours after injection. |
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In addition, never inject insulin into parts of your body that you use during
exercise because insulin would be absorbed into the bloodstream too quickly. If
you jog, do not inject insulin into your legs; if you weight-lift or play
tennis, stay away from sites in the arms and legs. |
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It is wise to check your blood-sugar level before you begin exercising. If
your blood-sugar level is low or in a normal range, you need a snack before
starting so that you prevent an insulin reaction. |
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Remember, an insulin reaction
is characterized by feelings of hunger, faintness, sweating, dizziness, and
confusion. An insulin reaction can occur while you exercise or up to 12 hours
later. |
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In fact, regardless of your blood-sugar level, you should eat within an hour
of exercising. If you do not eat a full meal, then eat a high-carbohydrate
snack, such as 6 oz of fruit juice or half a bagel before light to moderate
exercise (e.g., walking, biking, golf). If you plan to do heavier exercise
(e.g., aerobics, running, squash, handball), you may need to eat a little more,
such as half a meat sandwich and a cup of low fat milk. |
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These precautions will minimize the possibility of an insulin reaction, but
there are no guarantees. |
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That is why it is a good idea not to exercise alone if
you can prevent it. If you exercise with others, let somebody know that you have
diabetes and teach that person how to help you. If you prefer running or
cycling, ask a friend or relative to go with you. If you cannot find anyone to
go with you, let someone know where you are going and when you'll be back. |
What should I do if I do start to have an insulin reaction?
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Stop exercising immediately and drink a half cup of orange juice or
non diet soft drink or take three glucose tablets right away. |
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Treat an insulin
reaction as soon as you feel it. Do not wait, or it may become worse. |
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Whenever
you exercise, always bring along raisins or hard candy just in case you
need to raise your blood-sugar level. |
Are there special precautions for people with non insulin
dependent (type II)
diabetes?
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Exercise is particularly important for people with type II diabetes, since
diet and exercise are the two keys to controlling diabetes for many of them. |
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Exercise helps lower blood-sugar levels. |
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Exercise burns calories that would
otherwise be stored as excess weight. |
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Exercise is a valuable tool for preventing
heart disease. |
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Always check with your doctor before starting any exercise program,
especially because you do run a higher risk for heart disease. |
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If you use
insulin or oral diabetes medication, you should know your blood-sugar level
before you start exercising. If you are low, you will need a snack before you
begin. |
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