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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.

 

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.

 

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.

 

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.

 

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.

 

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.

 

 

ACTIVITY

Calories Spent
per minute

  Lying Down, Sleeping, Sitting

1 to 1.25

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)

2 to 2.5

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

2.5 to 4

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.

4 to 5

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 .

5 to 6

Walking at 4 mph, cycling at 10 mph, roller skating, horse riding (trot), gardening (digging), swimming (3/4 mph)

6 to 7

Walking at 5 mph, cycling at 11 mph, Badminton (competitive), tennis (social singles), light downhill skiing, water skiing

7 to 8

Jogging at 5 mph, cycling at 12 mph, basketball, vigorous downhill skiing, carrying loads of around 36 kgs

8 to 10

Running at .5.5 mph, cycling at 13 mph, playing squash (social level), Handball (social level), vigorous game of basketball.

10 to 11

 

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.

 

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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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