Diabetes and (Medical) Exercise

Perhaps the most distinguishing characteristic in the field of medical exercise is its application to patients with metabolic or cardiac abnormalities. The top three leading causes of premature death in the United States are heart disease, cancer and diabetes.

Despite their prevalence and economic burden, there should be more rehabilitation efforts directed to these conditions in terms of exercise prescription and post-rehabilitative care. There is a substantial amount of evidence that exercise may not only assist in the prevention of these disorders but that it also plays an intricate part of the treatment plan.

There are two types of Diabetes. Diabetes is defined as the body’s inability to metabolize carbohydrates. Insulin dependent diabetes mellitus [IDDM], in which the pancreas loses it’s ability to produce or secrete insulin. The second is non insulin dependent diabetes mellitus [NIDDM], where there is an inability of the muscle cell to uptake insulin from the blood stream making it necessary for the administration of medical intervention.

The medication used by many diabetics is insulin. Insulin is commonly injected under the skin into fatty tissue on the triceps region, abdomen, front of thigh and hip. The medical exercise specialist must inquire about the type of insulin(s) taken during the course of the day, number of injections per day, time of injections to determine appropriate time for exercise, body site preferred for injections (necessary for site specific exercises) while both the patient and fitness specialist must be aware of the times of peak insulin action.

Each type of insulin has an onset, a peak, and a duration time. The onset is how soon the insulin begins to lower your blood glucose once it has been administered. The peak is the time the insulin is working the hardest to lower your blood glucose. The duration is how long the insulin lasts (the length of time it keeps lowering your blood glucose).

For instance, long-acting/fast-acting forms are taken in the morning and evening to to cover the patients insulin requirements. Regular insulin (short acting type) is taken with meals covering glucose peaks which is dependent upon the carbohydrate content of the meal consumed. The correct combination of these types is necessary as it simulate’s the body’s response to a meal naturally. Since a person’s onset, peak, and duration times may vary, it is best to work with your health care team to come up with an insulin plan that works best for you.

The principle of individual differences must be applied when creating an exercise program for the client with special medical concerns and cannot be compared to that of the generally healthy individual. Specific guidelines must be adhered to, if overlooked, it can result in a serious medical emergency.

Studies show that long term physical conditioning lowers one’s blood glucose levels and makes the body more sensitive to insulin which then helps reduce overall resistance. When progress is monitored on a continual basis, the benefits will be noticeable. The main areas of focus with any conditioning program should include aerobic capacity, flexibility, muscular strength/endurance and motor skill development.[1]

Depending upon the type of exercise performed and the conditioning level of the participant, the blood glucose response will differ from one person to another. The diabetic client is constantly battling to avoid hypoglycemia on one hand and hyperglycemia on the other.

Hypoglycemia is a condition that occurs when the body’s blood sugar (glucose) falls below normal. Most healthy adults maintain fasting glucose levels above 4.0 mmol/L (72 mg/dl), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L.[2]

Hypoglycemia is of great concern. One on one training is beneficial for all special medical population groups because the specialist can provide assistance in the event of a medical emergency. The client should carry some form of carbohydrate with them at all times to prevent low blood sugars when symptomatic.

Hyperglycemia, or high blood sugar (not to be confused with hypoglycemia) is a condition in which an excessive amount of glucose circulates in the blood. This is generally a glucose level higher than 11.1 mmol/l (200 mg/dl), but symptoms may not start to become noticeable until even higher values such as 15–20 mmol/l (~250–300 mg/dl). A subject with a consistent range between 100 and 126 (American Diabetes Association guidelines) is considered hyperglycemic, while above 126 mg/dl or 7 mmol/l is generally held to have diabetes. Chronic levels exceeding 7 mmol/l (125 mg/dl) can produce organ damage.[3]

There can be secondary abnormalities due to long standing high blood glucose levels (hyperglycemia). It can cause deterioration to tissues, becoming more severe around the ten year mark. These complications include retinopathy (eye disease), neuropathy (nerve disease commonly affecting the feet first), myopathy (muscle disease/stiffness), microvascular disease (increasing the risk of heart disease).[4]

Interestingly, exercise allows glucose to get in the cells having a glucose lowering effect. Secondly, stored glycogen* in the muscles and liver can be converted into glucose through what is called gluconeogenesis to provide fuel to muscles during low blood glucose periods. A conditioning effect is usually evident after approximately the first 6 or 7 sessions.

Exercise prescriptions created for the diabetic client must include two important elements, intensity and duration.  The intensity of the fitness routine will equal how fast your heart rate increases and for how long.  The amount of time (duration) which is chosen for the exercise program will relate to an individual’s lifestyle, overall health, amount of weight required for loss and motivation factor.

If the initial level of fitness doesn’t allow the individual to exercise for more than 10 minutes, then incorporating a 10 minute fitness plan three times throughout the day will give similar benefits to doing 30 minutes all at once.  Then, as your fitness level improves, you will be able to maintain a greater intensity for an extended length of time.

It has been my experience through various case studies that conditioning sessions should depend on blood glucose levels. In other words, the higher levels constitute a far more vigorous and longer training session (more sugar to burn). Lower levels constitute a less vigorous session for less time, thus, assisting in the prevention of medical emergencies – highly unlikely if guidelines are followed correctly.

Perhaps the two most fundamental aspects of an ideal weight management program are dietary modifications and regular exercise. When starting ANY weight loss and exercise program, one MUST address all aspects of a person’s physical makeup, lifestyle concerns and behavioral components. There are many factors in determining what will work for each person.

Exercise and weight management programs will improve the quality of your life, it will motivate you as you continue to see positive results.  Incorporating a fitness program into your lifestyle benefits all as there is a lower risk of heart attack, stroke, peripheral vascular disease, heart disease, vascular disease, inflammatory disease and cancer.

Special medical concerns require special attention, please take it seriously because your life can depend on it. Find a specialist that will develop a safe and effective program that does not require the supervision of a licensed medical professional for exercise, however utilizing the parameters that are established by a licensed physician would be highly recommended and the safest way to go.

*Glycogen: Most carbohydrates are broken down in the body to a type of sugar called glucose, which is the main source of fuel for our cells. When the body has extra glucose, it stores it in the liver and muscles. This stored form of glucose is called glycogen. Glycogen is like your backup fuel. It releases glucose into the bloodstream when the body needs a quick energy boost or when a person’s blood glucose level drops.

[1]Family Doctor: Diabetes and Exercise http://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/treatment/diabetes-and-exercise.html
[2]Cryer, Philip E. (2001). “Hypoglycemia”. In Jefferson L, Cherrington A, Goodman H, eds. for the American Physiological Society. Handbook of Physiology; Section 7, The Endocrine System. II. The endocrine pancreas and regulation of metabolism. New York: Oxford University Press. pp. 1057–1092.
[4]The science and practice of rehabilitative exercise FT/ISSA
http:// kidshealth.org/kid/word/g/word_glycogen.html

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