Chapter 9 Exercise for Those with Diabetes Copyright

Diagnosis of diabetes • Fasting plasma glucose test – Measures blood glucose after 8 -hour fast – Meaning of values • ≤ 99 mg/d. L is normal • 100– 125 mg/d. L suggests prediabetes • ≥ 126 mg/d. L indicates diabetes Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagnosis of diabetes (cont'd) • Oral glucose tolerance test – Measures blood glucose after 8 -hour fast – Give patient a liquid with 75 g of glucose – Measure blood glucose 2 hours after intake – Meaning of values • ≤ 139 mg/d. L is normal • 140– 199 mg/d. L suggests prediabetes • ≥ 200 mg/d. L indicates diabetes Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Diagnosis of diabetes (cont'd) • Random plasma glucose test – Measures blood glucose without requiring a fast – A reading of ≥ 200 mg/d. L suggests diabetes if the patient also complains of frequent urination, excessive thirst, and unexplained weight loss – Follow with FPG or OGT test to confirm Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic and physiologic changes associated with diabetes • Role of the pancreas – Exocrine role • Produces digestive enzymes for digestion • 99% of its cells devoted to this role – Endocrine role • Releases hormones involved with blood glucose homeostasis • 1% of its cells devoted to this role Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic and physiologic changes associated with diabetes (cont'd) • Endocrine tissue of the pancreas – 4 types of cells produce 4 different hormones – Most important cells are the alpha and beta cells • Beta cells produce insulin • Alpha cells produce glucagon Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomic and physiologic changes associated with diabetes (cont'd) • Insulin – Facilitates the movement of glucose into cells when blood levels are high – Binds to receptors on target cells to open glucose gates – Promotes glycogenesis with low energy demands Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Effects of insulin on muscle, liver, and fat cells Copyright © 2011 Wolters Kluwer

Anatomic and physiologic changes associated with diabetes (cont'd) • Glucagon – Stimulates • Glycogenolysis • Gluconeogenesis • Lipolysis • Amino acid uptake • Ketone body formation Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Negative feedback loop for insulin and glucagon Copyright © 2011 Wolters Kluwer Health |

Hyperglycemia • Occurs when blood glucose levels remain elevated • Symptoms include – Sweating – Trembling – Rapid heart rate – Hunger – Frequent urination – Increased thirst Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Major types of diabetes • Type 1 diabetes mellitus – Autoimmune disorder in which immune cells attack beta cells in pancreas – Results in inability to produce insulin – Causes elevated blood glucose levels – Symptoms include hunger, severe systemic weakness, and weight loss Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Major types of diabetes (cont’d) • Type 2 diabetes mellitus – More common than type 1 – Pancreas continues to produce insulin, but insulin receptors on target cells are unresponsive – Blood glucose levels remain elevated, which promotes increased insulin production and release Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Risk factors for diabetes Copyright © 2011 Wolters Kluwer Health | Lippincott Williams &

Diabetes-related complications • High blood pressure • Heart disease • Stroke • Liver damage • Retinopathy • Neuropathy • Nephropathy • Poor circulation Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Precautions during exercise • Increased risk for cardiovascular disease • Increased risk of hypoglycemia • Increased risk of dehydration • Increased risks associated with high-intensity resistance training • Increased risk of injury to the extremities Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Benefits of exercise • Improved insulin sensitivity and glucose tolerance • Reduced risk for cardiovascular disease and improved work capacity • Reduced need for medication • Improved mood and well-being • Better weight management Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Exercise testing • Diabetics should receive medical clearance owing to their increased risk for cardiovascular, renal, neurologic, and visual problems • If at low risk of a cardiac event, diabetics may begin a low-to-moderate exercise program without testing • If at high risk, obtain a medically supervised graded exercise test Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Exercise guidelines • Begin with 5– 10 minutes of limbering movements followed by 5– 10 minutes of stretching; end with a 5 - to 10 -minute cool down • Cardiovascular training – Perform for 20– 60 minutes on 3– 7 days per week at a moderate intensity of 50– 80% VO 2 R (RPE of 12– 16) – Encourage low-impact activities like walking, floor aerobics, water aerobics, or the elliptical trainer – If neuropathy of the feet is present, encourage nonimpact activities like swimming or cycling Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Exercise guidelines (cont'd) • Resistance training – Safe in the absence of retinopathy, recent laser treatment, or any other contraindications – Perform on 2– 3 days per week at an intensity of 60– 80% of 1 RM – Complete 2– 3 sets, each consisting of 8– 12 repetitions for 8– 10 multijoint exercises – Rest at least 48 hours in between workouts Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Other special considerations • Hypoglycemia can occur during and after exercise • Hyperglycemia can occur in type 1 diabetics with poor blood glucose control • Those with neuropathy of legs and feet might have gait or balance problems; avoid quick changes • Participate in activity at the same time each day Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Other special considerations (cont'd) • Check blood glucose levels before exercising – If <100 mg/d. L, consume small amount of carbohydrates – If 100– 250 mg/d. L, begin exercise – If >250 mg/d. L, be careful; test for urine ketones and avoid exercise if ketone level is high • Have a source of carbohydrates available • Do not inject insulin into exercising limbs Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Other special considerations (cont'd) • Consume water before, during, and after exercise • Always exercise with a partner • Use perceived exertion to monitor intensity • Wear well-fitting, breathable shoes • Wear a medical ID bracelet Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tips for the diabetic exerciser Copyright © 2011 Wolters Kluwer Health | Lippincott Williams

When diabetics should avoid exercise Copyright © 2011 Wolters Kluwer Health | Lippincott Williams

Sample exercises • Upper body – Chest press – Lateral pull-down – Seated row

Sample exercises (cont’d) • Lower body – Leg press – Squats – Lunges –

Nutritional considerations • Carbohydrates – Consume at least 130 grams/day – Include about 14 grams of fiber per 1000 kcal – Strive to consume a similar amount each day, at the same time each day, and evenly spaced out each day – Select high-fiber foods, whole grains, and vegetables – Carefully plan insulin injections to avoid hyperglycemia or hypoglycemia Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional considerations (cont'd) • Protein – Should constitute about 15– 20% of a diabetic’s total energy intake (75– 100 grams on a 2000 -kcal diet) – If suffering from kidney disease, limit protein intake even more – Choose lean meats, chicken, and plant-based proteins like soy Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional considerations (cont'd) • Fat – Limit total daily fat intake to 20– 35% of total kcal – Limit saturated fat intake to <7% of total daily kcal – Limit dietary cholesterol intake to 200 mg/day Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional considerations (cont'd) • Alcohol – Moderate alcohol consumption is safe – Consume with foods if taking insulin – Be aware that many drinks like wine coolers and mixed drinks contain juices that are high in carbohydrates Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional considerations (cont'd) • Vitamins and minerals – Needs match those of the general population (see Appendix B) – If at high risk for cardiovascular disease, limit sodium intake to <2000 g/day Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

Nutritional considerations (cont'd) • Water – Recommendations resemble those for the general population • 2– 3 eight-ounce glasses 2 hours before exercise • 1– 2 cups 10– 15 minutes before exercise • 1– 1½ cups during exercise Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins