Exercise for Diabetes by Selim

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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mailto:[email protected]

DefinitionsDefinitions

Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state.


Physical Activity

Caspersen, et al., Public health Rep,1985

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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


The amount of energy expended during exercise relative to the energy expenditure during rest.


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

Classification of Exercise

Aerobic exercise: Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc…


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Classification of Exercise Classification of Exercise


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


Moderate: 3 – 6 MET

Vigorous: Above 6 MET

CDC, 1996 May 3, 2023May 3, 202388

Moderate & Vigorous IntensityModerate & Vigorous Intensity Physical Activities Physical Activities


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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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 Exercise & & DiabetesDiabetes

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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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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 Exercise in the in the Management of Management of

DiabetesDiabetes

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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 & 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 30 60 90 120 150 180

Before After


Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 DiabeticsP

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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

0

400

800

1200

1600

0 30 60 90 120 150 180

Before After


Response to Response to 100100 gg of glucose in mild Type 2 Diabetics of glucose in mild Type 2 DiabeticsP

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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


Exercise Prescription for Diabetic

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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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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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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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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


Exercise Exercise Prescription for Prescription for Special Cases Special Cases

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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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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.


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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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((

McArdle, et., 1991May 3, 2023 Exercise in Diabetes 31

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((

Ainsworth, et., 2000May 3, 2023 Exercise in Diabetes 32


How to Calculate How to Calculate Energy Expenditure Energy Expenditure during Brisk Walkingduring Brisk Walking!!

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== 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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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

Types of Physical Activity

The Mnemonic: “SAFE” exercises are recommended:

Strengthening exercises Aerobic exercises Flexibility exercises Endurance exercises

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.

http://japanesecentral.com/Siryoo/pictureclips/sports/jogging.jpg

http://japanesecentral.com/Siryoo/pictureclips/sports/swimming.jpg

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.

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.

http://www.leigh.org/running/photogallery/situp1.jpg

http://www.leigh.org/running/photogallery/bothkneesbent.jpg

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.

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

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 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.

Breathing Exercises

Neck Exercises

Hand Exercises

Trunk Exercises

Trunk Exercises…………

Leg Exercises

Peripheral and autonomic neuropathy

Recommendednon-weight-

bearing activities

swimmingbicyclingchair and arm

exercises

Contraindicated treadmillprolonged

walking joggingstep exercises

Nephropathy

RecommendedLow to

moderate intensity forms of exercise

ContraindicatedHigh intensity

forms of exercise

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.

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

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

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

What Can Physical Activity Do For You?

Give you more energy


Help you lose weight and keep it off

What Can Physical Activity Do For You?Increase

flexibility and strength

Slow bone lossProvide better

quality of life


Build muscle


Improve your sex life


Lift your mood

Treat depression


Reduce stress and anxiety


Improve blood glucose control

(lowers A1C)

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


Keep your heart healthy

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

“Sitting” through life increases your risk of:

heart disease high blood pressure high cholesterol overweight type 2 diabetes

We now must plan physical activity into our schedule

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

Aerobic Activity Walking briskly Dancing Bicycling Hiking Jogging/running Skating Stair climbing Swimming Water exercise

Resistance Activities

“Push, Pull, and Lift” Activities increase muscle strength prevent falls increase mobility improve blood glucose control

Stretching

Improves your balance and coordination

Makes you more flexible Reduces stiffness Reduces your risk of injury

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

Physical Activity Is Like Magic for Type 2

Diabetes

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Health & Medicine

Exercise for Diabetes by Selim