Studies show exercise is crucial to keeping diabetic patients healthy
Programs can be developed for just about anyone
There are plenty of studies demonstrating how exercise helps patients control the risks associated with diabetes — chances are good you already are a believer. But your patients may not share your enthusiasm unless you explain why keeping active is worthwhile to them. If you talk about these exercise benefits with your patients, you may be able to entice the sedentary to become active:
- If they have diabetes, exercise can reduce or even eliminate the need for medication to control their disease.
- For patients at risk of developing Type 2 diabetes, exercise and weight control often can prevent or delay the disease from developing.
- Those who maintain a sedentary lifestyle face dramatically higher risks of dying from a heart attack.
For many diabetics, it comes down to realizing exercise, like their medication, is essential to preserving their quality of life and helping them stay as healthy as they can. "How well a diabetic does depends very much on exercise," notes Paul Thompson, MD, president of the American College of Sports Medicine and cardiac director of preventive care at Hartford (CT) Hospital.
"I’d say anyone who wants to begin an intensive exercise program should see a doctor first. But a diabetic patient who is sedentary or obese should probably have a full cardiac evaluation first," says endocrinologist William Isley, MD, an associate professor of medicine at the University of Missouri in Kansas City and director of the dyslipidemia clinic at the Lipid and Diabetes Research Center at St. Luke’s Hospital, also in Kansas City.
Isley, a runner who has completed three marathons, urges clinicians and patients that persistence and moderation may produce better long-term results than an aggressive start that quickly fizzles out.
"While patients need to be active, being active in the usual daily activities may be better than joining a gym, being very diligent for 12 weeks, and then never going again," he says.
Isley says clinicians need to focus on exercise for patients of all age groups. Lately, the need to get patients moving is most apparent in what he calls an "epidemic" of Type 2 diabetes among teen-agers and children — whom he describes as "couch potatoes whose only exercise is the thumb on the remote."
Motivate, don’t intimidate
The idea is not to use scare tactics or rigid routines. Isley recommends a practical approach to getting patients to stay active: "Find out what the patient is willing to do and what the patient will tolerate."
Then patients should see results. Not only does exercise improve insulin sensitivity, it also increases high-density lipoprotein (HDL) levels and helps patients lose weight and generally feel better and more motivated, says Linda Haas, RN, PhC, CDE, president for health care and education of the American Diabetes Association and a clinician at the VA Medical Center in Seattle.
Haas has two warnings for this group of patients:
- Diabetics with signs of retinopathy should not run or engage in weight training.
- Those taking insulin or sulfonylureas should monitor their blood glucose carefully before and after exercise to determine if the activity is causing hypoglycemia.
Haas recommends individual assessments, including cardiac stress tests for all patients older than 35 who are planning to begin an exercise program, "since people with diabetes have a lot of asymptomatic cardiovascular disease."
She also supports the U.S. surgeon general’s recommendation for 20 to 30 minutes of exercise every day, but not necessarily all at the same time. Five- or 10-minute exercise breaks can be just as effective, Haas says. "If we can get folks to increase what they’re doing, that’s good."
The amount of exercise necessary for fitness has been the subject of great controversy. "It is extremely difficult to determine how much exercise is necessary to prevent the complications of diabetes in someone who is already diagnosed with the illness," notes Tedd Mitchell, MD, director of internal and sports medicine at the Cooper Clinic Aerobics Centers in Dallas.
It’s easier to look at healthy patients and compare their risk of developing the disease according to how active they are. Mitchell and other researchers at Cooper found that inactive men over 30 face nearly four times the risk of developing Type 2 diabetes compared with fit, physically active men.
Mitchell has some caveats of his own for diabetics beginning an exercise program:
o Know your sugar.
"People who are diabetic need to appreciate that if their sugar is uncontrolled with the onset of exercise [greater than 250 mg/dL], blood glucose can actually rise rather than fall during exercise," he says.
o Be aware of how you react to the time of day.
Hypoglycemia is more likely during night exercise than during daytime, Mitchell says, because of diurnal variation in growth hormone levels.
o Know the effects of insulin.
He also cautions that exercise performed shortly after taking a regular insulin injection can drop blood sugars dangerously because the exercise speeds up the absorption of insulin.
o Consider your body’s nutritional needs for longer workout sessions.
Mitchell also warns prolonged, intense exercise (activity lasting more than two hours such as marathons, triathlons, etc.) increase the need for supplemental food and should be accompanied by additional carbohydrate intake every 30 minutes.
While the Cooper study involved only men, Mitchell notes that it "would be our best guess" that the benefits would be seen in women and children as well.
Isley adds some studies suggests diabetes can cancel the hormonal protection that premenopausal women have from heart disease, so women should monitored as closely as men.
[William Isley can be reached at (816) 932-3100, Linda Haas at (206) 764-2721. Contact Tedd Mitchell at (972) 239-7223, Paul Thompson at (860) 545-5000, and Kathy Mullooly at (617) 732-2400.]
The Hard Facts
• About half of all diabetics have coronary artery disease (CAD).
• More than 50% of diabetics with CAD die from cardiovascular causes.
• The risk of cardiac death is three times higher in diabetics than in nondiabetic patients.
Guidelines for Diabetics and Their Caregivers
o Achieve appropriate blood glucose control before starting an exercise program.
o Check blood glucose levels before and after exercise to understand how blood glucose responds to various types of exercise and intensities.
o Keep exercise programs moderate and consistent, using:
• regular aerobic exercise (see note about retinopathy near end of this box);
• strength training (weightlifting) if there are no signs of retinopathy;
• flexibility and stretching.
o Understand that a regular exercise program may change medication needs over time. Patients’ need regular follow-ups with their health care team so personal status can be assessed and tracked.
o Be aware that exercise may change a patient’s nutritional and caloric needs.
o Remember that diabetics taking insulin should not inject it into the working muscle shortly before exercise. The abdomen is the best site.
o Avoid weightlifting and running if there are signs of retinopathy.
o Be sure to have frequent foot examinations after beginning an exercise program.
Getting a Big Bang for Your Exercise Buck
Activity Cost
Mall walking $50 for decent pair of walking shoes. Ask salesperson for advice on proper fit and brand for your needs. Keep an eye out for sales and discounts, too.
Dancing Free — if you do it at home.
Jumping rope No need to get fancy here. A 50-cent section of soft nylon rope with knotted ends works well. Wear supportive shoes and gradually work on how long you can jump rope at one time.
Homemade weights Free — if you use canned goods or other heavyweight items loaded into bags at home. Small hand or leg weights are fairly inexpensive, about $10.
Stair climbing Free — if you do it at home, at the mall, or in a public building.
Exercise videos Free — Borrow them from the library and make copies.
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