1. Physical Activity and Diabetes

2. Physical Activity Is Like Magic for Type 2 Diabetes

3. What Can Physical Activity Do For You? Give the patient more energy

4. What Can Physical Activity Do For You? Help us lose weight and keep it off

5. What Can Physical Activity Do For You? Increase flexibility and strength Slow bone loss Provide better quality of life

6. What Can Physical Activity Do For You? Build muscle

7. What Can Physical Activity Do For You? Lift your mood Treat depression

8. What Can Physical Activity Do For You? Reduce stress and anxiety

9. What Can Physical Activity Do For You? Improve blood glucose control (lowers A1C)

10. 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

11. What Can Physical Activity Do For You? Keep your heart healthy  Strengthening heart muscle  Lowering resting heart rate  Lowering blood pressure  Improving cholesterol  Reducing risk of heart attack and stroke

12. We now must plan physical activity into our schedule

13. 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

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

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

16. Stretching Improves your balance and coordination Makes you more flexible Reduces stiffness Reduces your risk of injury

17. 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

18. Start Slowly Set short-term goal for one week Do less than you think you can No Pain No Gain

19. Effect of Physical Activity on Blood Glucose Depends on:  your blood glucose level before you exercise  diabetes medication  when and how much you ate last  your physical fitness  type of activity

20. Effect of Physical Activity on Blood Glucose Blood glucose checks before and after exercise are the key

21. To increase compliance, the physician should help the patient choose a type of exercise he or she will enjoy, and offer regular encouragement and suggestions for overcoming barriers to exercise A reasonable initial regimen is 10 minutes of stretching and warm-up, followed by 20 minutes of gentle aerobic exercise such as walking, cycling, or rowing. The exercise should be performed regularly (at least 3 times per week) and preferably at the same time in relation to meals and insulin injections in patients treated with insulin. The duration and intensity of exercise should be increased gradually as tolerated by the patient.

22. Fluid intake should be maintained at a relatively high level before, during, and after exercise. For patients who take insulin (particularly those with type 1 diabetes), individual experimentation will be needed to make appropriate changes in the usual regimen when exercising.

23. General considerations include: Measure the blood glucose before, during and after exercise so that the changes in blood glucose can be documented and then predicted for subsequent exercise sessions] If the blood glucose concentration is over 250 mg/dL (13.9 mmol/L), exercise should be delayed until a lower level is achieved.

24. Effect of Physical Activity on Blood Glucose Physical activity usually lowers blood glucose Physical activity can raise your blood glucose if:  your BG is >250 mg/dl before your exercise and you have ketones  you’re starting a new vigorous exercise program

25. Physical Activity and Low Blood Glucose Low blood glucose can result from exercise only if you take:  insulin  oral diabetes medication (pills) sulfonylureas repaglinide

26. short-term effects in type 2 diabetes — The physiologic responses to exercise are modified in diabetes, depending upon the serum insulin concentration at the time of exercise and, for those treated with insulin, upon the site and timing of recent insulin injections. Well-controlled insulin-treated diabetic patients with adequate serum insulin concentrations will usually have a fall in blood glucose concentrations that is much larger than that in normal subjects

27. 1-Exogenous insulin cannot be shut off, thereby maintaining muscle glucose uptake and inhibiting hepatic glucose output. 2-The increased temperature and blood flow associated with exercise may speed insulin absorption from subcutaneous depots, resulting in higher serum insulin concentrations. 3- This effect is most prominent if the injection was recent, was given into an arm or leg that is being exercised or was inadvertently given intramuscularly

28. in contrast, exercise can cause a paradoxical elevation in blood glucose concentrations in diabetic patients with poor metabolic control (blood glucose concentration above 250 mg/dL,hypoinsulinemia, and some ketonuria. In these patients, the following factors come into play:  -The lack of insulin impairs glucose uptake by muscles and cannot prevent an increase in hepatic glucose output that is mediated by counterregulatory hormones, particularly epinephrine, cortisol, and growth hormone. These hormonal changes also lead sequentially to increased lipolysis and enhanced conversion of the free fatty acids to ketones

29. Recommendations People with diabetes should be advised to perform at least 150 min/week of moderate-intensity aerobic physical activity (50–70% of maximum heart rate). In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training three times per week

30. Exercise is an important part of the diabetes management plan. Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being. Regular exercise may prevent type 2 diabetes in high-risk individuals

31. Structured exercise interventions of at least 8 weeks’→ lower A1C by an average of 0.66% in people with type 2 diabetes, even with no significant change in BMI Higher levels of exercise intensity are associated with greater improvements in A1C and in fitness

32. suggest that adults over age 18 years do 150 min/week of moderate-intensity, or 75 min/week of vigorous aerobic physical activity, or an equivalent combination of the two. the guidelines suggest that adults also do muscle-strengthening activities that involve all major muscle groups two or more days per week.

33.  The guidelines suggest that adults over age 65 years, or those with disabilities, follow the adult guidelines if possible or (if this is not possible) be as physically active as they are able.  Studies included in the metaanalysis of effects of exercise interventions on glycemic control (146) had a mean number of sessions per week of 3.4, with a mean of 49 min/session

34. Progressive resistance exercise improves insulin sensitivity in older men with type 2 diabetes to the same or even a greater extent as aerobic exercise for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes

35. Evaluation of the diabetic patient before recommending an exercise program Prior guidelines suggested that before recommending a program of physical activity, the provider should assess patients with multiple cardiovascular risk factors for coronary artery disease (CAD). Coronary heart disease screening and treatment, the area of screening asymptomatic diabetic patients for CAD remains unclear, and a recent ADA consensus statement on this issue concluded that routine screening is not recommended

36. High risk patients should be encouraged to start with short periods of low intensity exercise and increase the intensity and duration slowly.

37. patients for conditions that might contraindicate certain types of exercise or predispose to injury, such as uncontrolled hypertension, severe autonomic neuropathy, severe peripheral neuropathy or history of foot lesions, and unstable proliferative retinopathy. The patient’s age and previous physical activity level should be considered.

38. Exercise in the presence of nonoptimal glycemic control Hyperglycemia. Hyperglycemia. vigorous activity should be avoided in the presence of ketosis Hypoglycemia. In individuals taking insulin and/or insulin secretagogues, physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not altered. For individuals Carbohydrate should be ingested if pre-exercise glucose levels are 100 mg/dl (5.6 mmol/l).

39. Exercise in the presence of specific long-term complications of diabetes Retinopathy. In the presence of proliferative diabetic retinopathy (PDR) or severe nonproliferative diabetic retinopathy (NPDR), vigorous aerobic or resistance exercise may be contraindicated because of the risk of triggering vitreous hemorrhage or retinal detachment

40. Peripheral neuropathy Decreased pain sensation in the extremities results increased risk of skin breakdown and infection and of Charcot joint destruction. Prior recommendations have advised non–weight- bearing exercise for patients with severe peripheral neuropathy. However, studies have shown that moderateintensity walking may not lead to increased risk of foot ulcers or reulceration in those with peripheral neuropathy

41. Peripheral neuropathy  All individuals with peripheral neuropathy should wear proper footwear and examine their feet daily to detect lesions early. Anyone with a foot injury or open sore should be restricted to non–weight-bearing activities.

42. Autonomic neuropathy Autonomic neuropathy can increase the risk of exercise induced injury or adverse event through decreased cardiac responsiveness to exercise, postural hypotension, impaired thermoregulation, impaired night vision due to impaired papillary reaction, and unpredictable carbohydrate delivery from gastroparesis predisposing to hypoglycemia

43. People with diabetic autonomic neuropathy should undergo cardiac investigation before beginning physical activity more intense than that to which they are accustomed.

44. Albuminuria and nephropathy. Physical activity can acutely increase urinary protein excretion. However, there is no evidence that vigorous exercise increases the rate of progression of diabetic kidney disease, and there is likely no need for any specific exercise restrictions for people with diabetic kidney disease

45. What Is Happening to? She takes insulin and is walking briskly in her neighborhood in the late afternoon. She becomes shaky, is unable to think clearly, and has changes in her vision. What should Sandra do?

46. Treatment for Low Blood Glucose Equal to about 15 grams of carbohydrate: ½ cup fruit juice ½ cup soft drink (not diet) 3 glucose tablets 8 Lifesavers Glucose Tablets

47. Physical Activity and Hypoglycemia More common after physical activity Body is replenishing stored carbohydrate (glycogen) Check your blood glucose after you exercise

48. How Can Sandra Prevent Low Blood Glucose Next Time? Adjust Insulin For planned, regularly scheduled physical activity Eat Snack For unplanned physical activity When exercising for an extended period of time Check blood glucose before, during, and after exercise

49. Carbohydrate Snacks for Physical Activity IntensityTime (minutes) Carbohydrate MildLess than 30May not be needed Moderate30-6015 grams HighOver 6030-50 grams

50. Exercising With Diabetes Complications If you have diabetes complications:  An exercise stress test is recommended  Don’t consider diabetes a barrier to exercise Most moderate lifestyle activities are safe Some activities may need to be modified

51. Exercising With Heart Disease Caution: Very strenuous activity Heavy lifting or straining Exercise in extreme cold or heat Choose: Moderate activity such as walking, swimming, biking, gardening Moderate lifting, stretching

52. Exercising with Hypertension (high blood pressure) Caution Very strenuous activity Heavy lifting or straining Choose Moderate activity like:  walking  weight lifting with light weights  stretching Make sure your blood pressure is in control first

53. Exercising with Retinopathy (eye disease) Caution Strenuous exercise Heavy lifting and straining High-impact aerobics, jogging Bending your head below your waist – toe touching Choose Moderate, low-impact activities:  walking  cycling  water exercise Moderate daily chores that don’t require lifting or bending your head below your waist

54. Exercising with Nephropathy (kidney disease) Caution Strenuous activity Choose Light to moderate activity like walking, light housework, gardening, water exercise

55. Exercising with Neuropathy (nerve disease) Caution Weight-bearing, high impact, strenuous, or prolonged exercise:  jogging/running  step exercise  jumping  exercise in heat/cold Choose Low impact, moderate activities:  biking  swimming  chair exercises  stretching  light to moderate daily activities Check feet after exercise

56. Exercise Safely Check your blood glucose before and after exercise Don’t exercise if your blood glucose is too high or too low Carry carbohydrate to treat low blood glucose if you are at risk

57. Exercise Safely Stop exercising if you feel pain, lightheaded, or short of breath Avoid strenuous activity in extremely hot, humid, or cold weather Wear proper shoes for the activity to reduce the risk of injury

58. Exercise Safely Wear diabetes identification Include warm-up and cool-down sessions Drink plenty of fluid