Considerations for Exercising with Diabetes

There are a few things that are really important to consider as a diabetic when exercising.

The biggest problem, as mentioned previously, is hypoglycemia (blood sugar <70 mg/dL). Those most at risk of developing hypoglycemia are those of you taking insulin or oral drugs that increase insulin secretion, such as sulfonylureas. Unfortunately, hypoglycemia is relative and symptoms may be present due to rapid drops in blood sugar, even if levels are well above 70 mg/dL. Symptoms of hypoglycemia include: shakiness, weakness, abnormal sweating, nervousness, anxiety, tingling of mouth and fingers, and hunger. Conversely, you may experience no symptoms as blood sugar levels rapidly decline with exercise.

When there is a shortage of glucose to the brain (called neuroglycopenia, a big concern because the brain's main source of fuel is glucose), symptoms include: headache, visual disturbances, mental dullness, confusion, amnesia, seizures, and coma.

It is important to be aware that hypoglycemia and its effects may delayed up to 12 hours after exercise, so monitor blood sugar levels closely before and for several hours after exercise. This is especially important if you are new to exercising. For diabetic exercisers, it is critical to exercise with a partner to reduce the risk of complications due to hypoglycemia.

Timing is of utmost importance with diabetes and exercising. If you use insulin, you made need to change timing, dosage, and carbohydrate consumption to prevent hypoglycemia from occurring during or after exercise. Those of you not on insulin will also need to adjust carbohydrate and medication intake before and after exercise based on your blood sugar level and exercise intensity to prevent hypoglycemia. For nearly all of you, modification will require physician supervision and experimentation to help determine exactly how your body reacts to new combinations of drugs and exercise.

Monitoring blood sugar for extended periods of time will be useful in determining the patterns of blood sugar levels and both immediate and long-term effects of exercise. This will ultimately allow you to fine-tune your carbohydrate and medication intake before and after exercise.

If you have Type 1 DM, hyperglycemia can be a problem if you do not have controlled blood sugar levels. Symptoms of hyperglycemia include: excessive urination, fatigue, weakness, excessive thirst, and acetone breath (a fruity odor). If you are hyperglycemic with no symptoms or ketone bodies (ketone bodies are the by-products of breaking down fats for energy) present in the blood or urine, you may exercise, but be sure to check blood sugar often and do not partake in vigorous-intensity exercise until blood sugar goes down.

If you are hyperglycemic and urinating frequently, you are at an increased risk of developing a heat-related illness and should be monitored closely for the signs and symptoms of that, as stated by the CDC. Take special note of their tips for people with chronic medical conditions.

Having DM and retinopathy puts you at an increased risk of retinal detachment and vitreous hemorrhage. Avoid exercise that dramatically elevates blood pressure. If you have severe diabetic retinopathy, you should avoid both vigorous aerobic exercise and resistance exercise.

If you have peripheral neuropathy (damage to nerves going out from the brain and spinal cord to arms, legs, hands, feet, etc.), be sure to take proper care to prevent ulcers and blisters on your feet, since you will be less likely to feel them forming. Keep your feet dry and use shoe inserts and absorbent socks.

Lastly, as an individual with DM or prediabetes, you are at a high risk for, or possibly even have, cardiovascular disease (CVD). As such, you should take even greater care to progress exercise slowly and be sure to listen to whatever your body is telling you (most especially if you are experiencing the signs and symptoms of heart attack or stroke, as outlined by the NIH's branch the National Heart, Lung, and Blood Institute).

Unfortunately, there are a lot of precautions to take before exercising. However, there are plenty of benefits, as outlined in my previous post "Exercise Prescription for Diabetics", the most exciting of which is that Type 2 DM can be prevented, and sometimes reversed, if a regular exercise program is started early enough.

Thanks for reading!
-Emalee


Information for this blog came from the ACSM's Guidelines for Exercise Testing and Prescription, 9th edition (2014) and the websites for the Centers for Disease Control and Prevention and the National Institutes of Health.

Exercise Prescription for Diabetics

The Exercise Prescription for individuals with diabetes is pretty similar to that for individuals without the disease. The big difference is that diabetic exercisers must be cautious of hypoglycemia, or low blood sugar, which I will discuss in greater depth in a future blog.

To begin, I want to highlight for you all the great benefits of exercising for individuals with diabetes and prediabetes. Regularly exercising can help improve glucose tolerance, increase insulin sensitivity, and decrease HbA1C (aka glycosylated hemoglobin, which is a reflection of the average blood glucose control over a period of 2-3 months, with a typical goal being <7%) in those of you with Type 2 diabetes and prediabetes. Individuals using insulin (Type 1 diabetics and some Type 2 diabetics) can experience a reduction in insulin needs with regular activity. For those of you with any of the three conditions, exercise can help improve a number of CVD risk factors (i.e. lipid profiles, blood pressure, weight) and overall well-being. In addition, if you have prediabetes and are at high risk to develop DM, exercise can help delay, and sometimes even prevent, the transition to Type 2 diabetes. Lastly, regular exercise can be used as a means of weight loss or weight maintenance, which is especially important if you have Type 2 DM or prediabetes, but it can also be helpful if you have Type 1 DM.

In exercise science, we use FITT - Frequency, Intensity, Time, and Type - to build exercise programs; we also throw in a very important rule: Progression. Exercise programs should consist of aerobic training (aka cardiorespiratory fitness, such as walking, running, cycling, etc.), resistance training (aka strength training, such as weight lifting, using resistance bands or physio-balls, etc.), and flexibility (stretching for pre-exercise warm-up and post-exercise cool down). For individuals with DM, the FITT guidelines are as follows:

1. Frequency - 3-7 days/week
2. Intensity - RPE 11-13 on a scale of 6-20; better glucose control could be achieved at higher intensities, so if you have been participating in regular exercise, you may consider increasing the intensity to RPE 14+
3. Time - 150+ min/week of moderate intensity exercise, performed in bouts of 10 minutes or more and spread out throughout the week; exercising 300+ min/week at moderate-to-vigorous intensities can have even greater health benefits
4. Type - the best exercises are those that use large muscle groups (shoulders, chest, back, abs, arms, thighs, calves); the particular type of exercise can and should be tailored to your individual goals and interests
5. Progression - it is of utmost importance to gradually progress frequency, intensity, and time of exercise to maximize calories burned and to increase health benefits, as well as prevent boredom from an unchanging program and injury from progressing too quickly

• As long as you do not have any contraindications to exercise (please see the second and third blog posts for these!), retinopathy, or recent laser surgery, resistance training should be incorporated into your program
• 2-3 days/week; light-to-moderate intensity; work all the major muscle groups listed in #4 (type) above; 8-20 repetitions, 2-4 sets, 30 sec-2 min rest between sets (all vary depending on the goal of the program); at least 48 hr rest between resistance training workouts; gradual progression
• Exact resistance training programs will vary from person to person because they should be designed for the individual
• Another important aspect of the exercise program is flexibility exercise
• You should warm up and cool down before and after every bout of exercise; warm up should be dynamic stretching that incorporates movement into the stretching (i.e. high knees, butt kicks, walking lunges, etc.), while cool down can be static (standing or seated, such as toe touches, butterflies, etc.) stretching
• 2-3+ days/week (can be done every day - the more you stretch the better you will be); stretch to the point of slight discomfort; hold each stretch for 20-30 sec (hold longer if older); perform enough reps (2-3) that you perform each exercise for 60 sec

Combining both aerobic and resistance training may have a greater effect on glucose control than simply partaking in one or the other, although there is still some research to be done in this field. You should take no more than 2 days off each week. To increase cardiorespiratory fitness (CRF), you should eventually focus on vigorous intensity exercise. If the goal is weight loss (as is the case for many individuals with Type 2 DM), then you should look at performing longer bouts of moderate intensity exercise incorporated with, if it is right for you, calorie restriction.

For the most part, children with diabetes can play as much as their peers who do not have DM, but be sure to look out for hypoglycemia both during and after exercise. For more information on exercise and children with DM, check out the ADA website or talk to your child's physician.

The big takeaway from this is that, even though each of you has diabetes or prediabetes, there is an exercise program out there that is tailored specifically and individually for you. In the next few posts, I am going to discuss some considerations for diabetics while exercising, as well as present a sample exercise program for you to see the FITT principles in action!


Have a great day!
-Emalee


Information for this blog came from the ACSM's Guidelines for Exercise Testing and Prescription, 9th edition (2014) and the website for the American Diabetes Association.

Exercise Testing for Diabetics

After giving you a general overview of exercise testing with my last post, I want to focus specifically on exercise testing and diabetes in this one.

When beginning an exercise program at light-to-moderate intensity exercise, individuals with DM or prediabetes might not need an exercise test if they are asymptomatic and low risk for CVD (as determined with tables 1 and 2 from the previous post). However, it is certainly in your best interest to receive physician guidance anyways. You should be tested before performing moderate-to-vigorous exercise if you have one or more of the following:

• age >35yr
• Type 2 DM >10yr
• Type 1 DM >15yr
• total cholesterol >240mg/L
• blood pressure >140/90
• smoking
• family history of coronary artery disease in parent or sibling <60yr
• presence of microvascular disease
• peripheral artery disease
• autonomic neuropathy

If you have any serious heart problems, you MUST see your doctor before beginning absolutely any kind of physical activity. One big issue with diabetic patients is that, sometimes, ischemia (lack of blood flow to a tissue) goes undetected. Therefore, it is of utmost importance to see your doctor annually so your CVD risk factors can be assessed.

The last issue I would like to discuss is intermittent claudication, which is the pain that occurs in a muscle with an inadequate blood supply that is stressed by exercise. Diabetics are at an increased risk for developing intermittent claudication. Detailed symptoms of this disorder include pain that does not occur with standing or sitting, is reproducible from day to day, is more severe when walking up stairs or a hill, and is often described as cramping that disappears a couple minutes after exercise is finished. Patients with intermittent claudication are at an increased risk of developing coronary artery disease.

To summarize, it is very important for diabetic patients to receive physician guidance and clearance for exercise in order to prevent more serious cardiac disorders from developing.

Thanks for reading!

-Emalee

Information for this blog came from the ACSM's Guidelines for Exercise Testing and Prescription, 9th edition (2014).

Introduction to Exercise

For my second post, I want to give you a basic introduction to exercise, including defining some terms that you will probably see me use in future posts. If you are new to exercising or have not done it in a while, hopefully this will be helpful for you!

Before starting an exercise program, it is really important to determine if you need an exercise test and physician clearance. A great form is "Par-Q and You", a simple questionnaire from the Canadian Society for Exercise Physiology that you can fill out to help determine if you should see a physician before exercising. Another good guide is the "Health/Fitness Facility Preparticipation Screening Questionnaire" by the AHA and ACSM. Please note that, for all diabetic patients, it is best to see a physician before starting an exercise program (but more information on exercise testing and diabetes in the next post!).

The reason for pre-participation physician screenings is to ensure there are not any contraindications of exercise present. According to the ACSM's Guidelines for Exercise Testing and Prescription (9th ed., pg. 21-22), major signs and symptoms of cardiovascular, pulmonary, and metabolic disorders include: pain or discomfort in the chest, neck, jaws, or arms; shortness of breath at rest or with mild exertion; dizziness or loss of consciousness; dyspnea (abnormally uncomfortable awareness of breathing) at night that is relieved by sitting up or standing; swelling in the ankles; heart palpitations or fast resting heart rate (>100 bpm); intermittent claudication (pain in a muscle that is stressed by exercise, more information on this in the next post); heart murmur; and unusual fatigue or shortness of breath with normal activities.

Below are two important tables from the ACSM's Guidelines. The first table are the risk factors and defining characteristics of each for Atherosclerotic Cardiovascular Disease (CVD). The second table is a flow chart of need for exercise testing based on risk classification for CVD. Having only one risk factor puts you at low risk for CVD, having two or more puts you at moderate risk, and having a known cardiovascular, pulmonary, renal, or metabolic (diabetes!) disease puts you at high risk.

Atherosclerotic CVD Risk Factors and Defining Criteria

Exercise Testing Based on Risk Classification for CVD

Proper exercise programs should include cardiovascular training, resistance/strength training, and flexibility exercises. Exercise intensity is very important and can be defined by a variety of terms. One commonly used by professionals is MET level, with increasing METs being equivalent to increasing intensity. For example, walking at 3 mph is 3.0 METs, while jogging at 6 mph is 10.0 METs. An easy way to measure intensity while working out is by using heart rate (HR). Depending on the desired goal of exercise, exercisers should stay within a specific HR range (for instance, an unfit individual trying to lose weight should aim for HR = {[(220-age)*(0.40)] + 10 bpm}, with the target HR being 40% (0.40) of the maximum (220-age)). Trainers may use slightly more complicated (and accurate) equations to find the maximum HR, including the Karvonen Method. There are a number of charts available that measure RPE, or the Rate of Perceived Exertion. Popular in exercise science is a chart that ranges from 6-20, but modified ones are also available. As intensity increases, so does RPE (research also shows that, for the most part, HR also increases with RPE). Lastly, and very popular among older populations, is the "Talk Test". Using this test, an exerciser should be able to talk while exercising without getting too winded.

Light intensity exercise is <3.0 METs, HR not much above resting, and 6-9 on the RPE scale. Moderate intensity is 3-<6 METs, HR 40-60% maximum predicted HR, and 11-13 on RPE. Vigorous intensity exercise is 6+ METs, HR 60-100% max HR, and 15+ on RPE.

This concludes my short introduction to starting exercise. Look for my next post, which will be about exercise testing for diabetic individuals! Please post any comments or questions, if you have any!

Peace,

Emalee


Information for this blog came from the ACSM's Guidelines for Exercise Testing and Prescription, 9th edition (2014).

Welcome!!

Hello! My name is Emalee and I would like to welcome you to my blog about living through diabetes!

For those of you suffering with diabetes, you may or may not be aware of the physiology of the disease. If you are unaware or a caregiver/friend/family member of a diabetic interested in more information, I will use this introductory post to explain some of the particulars of the illness.

Formally called Diabetes Mellitus (DM), diabetes is a metabolic disease characterized by hyperglycemia, or high blood sugar (fasting blood glucose >125 mg/dL or non-fasting blood glucose >200 mg/dL). This occurs as a result of problems with insulin secretion and/or the inability to utilize insulin produced by the pancreas. There are several types of diabetes that you may suffer from: Type 1, Type 2, or gestational, with Type 2 diabetes being the most common (90% of all cases in the US). Typically, Type 2 diabetes is referred to as adult-onset diabetes, but it is becoming more and more common in children due to a shift towards sedentary lifestyles and improper nutrition (for more info on childhood obesity, check out this special series by HBO: "Weight of the Nation").

Type 1 diabetes is usually an autoimmune disease (the body fighting itself), where the insulin-producing cells in the pancreas are destroyed. Therefore, Type 1 is referred to as "insulin-dependent" diabetes, with patients being required to inject insulin to make up for their deficiency. Type 2 diabetes is caused by insulin-resistance in the muscles, liver, and fatty tissue, combined with a defect in insulin secretion. A common feature of patients with Type 2 diabetes is overweight and obesity. Gestational diabetes is diagnosed during pregnancy and may be reversible after delivering the baby.

Some of you may be suffering from prediabetes - a state of elevated blood glucose (fasting blood glucose 100-125 mg/dL or non-fasting blood glucose 140-199 mg/dL). For those of you who fall into this category, it is imperative that you start modifying your behaviors now to help prevent the onset of the disease.

Check out this link to see if you are at risk for Type 2 diabetes: http://www.diabetes.org/ are-you-at-risk/diabetes-risk-test/. Some signs and symptoms include: frequent urination, feeling very hungry or thirsty, and more. If you experience any of these, or others as noted by the American Diabetes Association website, I encourage you to see your physician. Remember, the earlier you start to fight it, the more you reduce your chance of developing serious complications from it!

Next time, I hope to start giving some tips on incorporating physical activity into your life. In the meantime, I encourage you to check out the American Diabetes Association for more information on the disease.

Note: many of the things presented in this blog will be focused more on adult populations; please take note if you are the parent of a diabetic child. I will try to add in some of the changes that should be made for children, but be aware and definitely see your child's physician for more personalized information!

Have a wonderful day!

-Emalee

Information for this blog came from the American College of Sports Medicine (ACSM) Guidelines for Exercise Testing and Prescription, 9th edition (2014) and the website for the American Diabetes Association.