Hanjabam Barun Sharma  ( Department of Physiology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India )
Sahil Madan  ( Chronic Disease Management Programmes, Phablecare, Bangalore, India )
Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital, Karnal, India; University Center for Research & Development, Chandigarh University, India. )

Physical fitness is an essential part of, and an important means of, ensuring and maintaining good health. Exercise is a physical activity which is designed for improvement or maintenance of physical fitness. Pursuit for fitness should be an integral aspect of one’s lifestyle, and hence one should engage in regular physical activity, exercises, games, sports and martial arts. Persons living with diabetes often find it challenging to pursue a proper exercise regimen in an effective, yet safe, manner. In this communication, we suggest a strategy to kick start a physical fitness regimen that one can adhere to. This simple suggestion will be helpful not only for persons living with diabetes and other chronic diseases, but for their health care providers as well.

 

Keywords: Diabetes, exercise, exercise medicine, lifestyle modification, person centred care, sports medicine

 

DOI: https://doi.org/10.47391/JPMA.23-26

 

Introduction

 

Physical fitness is an essential part of, and an important means of, ensuring and maintaining good health. There are five health-related (cardio-respiratory endurance, body composition, muscular strength, muscular endurance and flexibility) and six skill-related components (agility, coordination, balance, power, reaction time and speed) of physical fitness; and each one of them is important for our health.¹ Exercise is a physical activity which is designed for improvement or maintenance of physical fitness.^1,2 Pursuit for fitness should be an integral aspect of one’s lifestyle, and hence one should engage in regular physical activity, exercises, games, sports and martial arts etc. In this communication, we suggest a strategy to kick start a physical fitness regimen that one can adhere to (Table). This simple suggestion will be helpful not only for persons living with diabetes and other chronic diseases, but for their health care providers as well.

 

 

Physical Fitness and Diabetes

 

Low fitness and excess adiposity are strong predictors of diabetes and its complications, especially type 2 diabetes;³ which is also true for prolonged sedentary time.¹ Hence, routine physical activity and exercise should be part of daily life of every one living with diabetes.^4,5 However, it is challenging, for persons living with diabetes to initiate and sustain a physical fitness programme. Biomedical issues such as the risk of glycaemic variability, suboptimal bone, muscle and joint health, vascular dysfunction including hypertension, and impaired cardiorespiratory fitness contribute to this;^1,6 so are various psychosocial factors. Psychosocial factors, including lack of self-confidence and self- determination, as well as lack of qualified physical fitness trainers who are trained in diabetes management, may act as major obstacles too.

For the exercise naive, a hierarchy of exercise initiation and intensification should be followed, to maximize safety, satisfaction with outcomes, and sustainability. Professional fitness training for persons living with type 1 diabetes is now available online as well. This is usually offered as part of a digital therapeutics programme, and is conducted by qualified physiotherapists, fitness trainers or exercise specialists.

 

Precautions and Safety Considerations

 

It is always advisable for a person with diabetes who has been mostly sedentary and starting exercise programme especially of vigorous intensity, to undergo pre-participation evaluation and screening, as well as sports and exercise medical clearance.^1,7 However, exercise testing before starting low-moderate exercise programme is generally not needed for individuals with diabetes, and not having any CVD (cardiovascular diseases) related symptoms or are at low risk. It is important, however, for the health care providers as well as exercising individuals with diabetes to take care of certain precautions and safety considerations.^1,6-12 Cardiovascular assessment needs to be done for persons with autonomic neuropathy. Stress testing may be done before regular exercise programmes for those with microalbuminuria and proteinuria. It is to be noted that silent ischaemia can be missed easily in individuals with diabetes. Those with active foot diseases need to avoid weight-bearing exercise and aquatic physical activities. Proper care of one’s feet is absolutely essential. Those individuals with diabetes having proliferative or severe-non proliferative retinopathy need to avoid vigorous aerobic exercise, resistance exercise, jarring or jumping activities, Valsalva maneuver and minimize activities which increase blood pressure dramatically. Resistance exercise also needs to be avoided if one has had laser surgery treatment recently, or having uncontrolled hypertension.

Blood glucose monitoring before, after and, if needed, during exercise is another important consideration for individuals with diabetes.^1,6-8,10,12 Pre exercise plasma glucose of 120-180mg/dl may be preferably, with no exercise to be done in case of >300mg/dl, or >200-250mg/dl plasma glucose with presence of ketones in urine. Hypoglycaemia is a relative contraindication for starting any acute exercise session. Monitoring and early detecting of hypoglycaemia associated signs and symptoms should be done. One should however, keep in mind the possibility of hypoglycaemic unawareness too. Exercising with a partner or under supervision is therefore preferred.

One needs to keep glucose or carbohydrate snack nearby while exercising, especially when pre-exercise blood glucose is <100mg/dl for low intensity, 0.5hr exercise; <180mg/dl for moderate intensity, 1hr exercise; and ≤300mg/dl for strenuous intensity, 1-2hr exercise etc. As per requirement, one may need to take about 15/20-30g of glucose or carbohydrate at start and after every 0.5hr of vigorous exercise. One should keep in mind that a single aerobic exercise may increase insulin action up to 2 to 72hr after the exercise. Appropriate dose adjustment in insulin or insulin secretagogues may need to be done for regularly exercising individuals with diabetes. There is additive effect of insulin and muscle contraction on glucose uptake by muscles. Post-exercise hypoglycaemia may sometimes occur up to 12 hours or more, although the risk is highest during or just after the exercise. Early morning moderate exercise may, however, cause elevation rather than fall in blood glucose level.

Appropriate dose or timing adjustment in insulin or insulin secretagogues may need to be done for regularly exercising individuals with diabetes, to maintain euglycaemia. Dietary adjustment should also be done accordingly. Adequate hydration is another priority for those with diabetes. However, there may also be transient rise in blood glucose with intense brief anaerobic or resistance exercise. Hence, a short, high intensity interval exercise during aerobic exercise of moderate intensity may help in reducing the decline of blood glucose level in the early part of recovery period. Vigorous intensity exercise of any type may also result in increased glucose level.

 

Exercise Prescription and Diabetes

 

Following the principles of exercise prescription, adequate and effective exercise programmes should be designed for all living with diabetes.^1,6,7,10-13 It is advisable to engage in both aerobic and resistance type of exercise, rather than focusing only on one modality. One should consider frequency, intensity, type, time duration, volume and progression of exercise while prescribing. Exercise should always be started at low intensity for short duration and low volume, and then progressed slowly as per the need. Most of the exercise associated complications arise due to “too much, too soon”.

Aerobic exercise like walking, cycling or swimming may be encouraged on 3 to 7days per week, at 11-12 RPE to 14-17 RPE (RPE is the Borg’s Rating of Perceived Exertion) intensity for 150 min per week for moderate intensity or 75 min per week for vigorous intensity. Exercise intensity using RPE is preferred as autonomic dysfunction may blunt heart rate or blood pressure response to exercise, and VO2 kinetics. Approximately 8-10 types of resistance exercises targeting major muscle groups of the body, which may be machine-based or using free weights, need to be done on 2-3days per week (non-consecutive days), with an intensity of 50-69%1RM (one-repetition maximum), 1-3 sets of 10-15 repetitions to near fatigue per set. Progression may be done with higher intensity of 70-85%1RM or heavier weights at 8-10 repetitions in 1-3 sets. Additionally, stretching and flexibility exercises may be added, atleast 2-3 days per week. Stretching needs to be done to the point of tightness or slight discomfort, holding the stretched position for 10-30 seconds, in case of static stretching, and repeated 2-4 times. Other types of stretching like dynamic and PNF (proprioceptive neuromuscular facilitation) may also be done as per requirement.

 

Summary

 

High physical fitness is associated with low risk of diabetes as well as its complications. Each of the five health-related and six skill-related physical fitness components has significant impact on our health. It is, however, challenging, for persons living with diabetes to initiate and sustain a physical fitness programme, due to multiple factors including biomedical and psychosocial reasons. We as health and fitness professionals, should address all barriers, and successfully incorporate exercise and fitness not only as a part of holistic management of diabetes, but also as a way of life or simply a lifestyle choice.

Any exercise programme should be started at low intensity for short duration, and progressed slowly as per the requirement. Sports and exercise medical clearance, as well as pre-participation evaluation and screening is advisable before starting exercise programmes, especially of vigorous intensity, for persons with diabetes who have been mostly sedentary. Blood glucose monitoring is essential for all persons with diabetes, and especially for those on an exercise regimen. A readily available food source of glucose should be kept while exercising. Dose adjustment in insulin or insulin secretagogues may be required for regularly exercising individuals. It is advisable for persons with diabetes to do aerobic exercise of atleast 150min per week of moderate intensity or 75 min of vigorous intensity, or equivalent combination, done 3-7 days per week. Moderate to vigorous resistance exercise needs to be done on 2-3 non-consecutive days per week. Appropriate stretching exercise may also be done at least 2-3 days per week.

 

References

 

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2.      Sharma HB. Sports Physiology. PG Pathshala-Biophysics, P-13 Physiological biophysics, M-31 Sports Physiology 2020. [Internet]. Cited on 4th August 2022. Available from: https://epgp.inflibnet. ac.in/Home/ViewSubject?catid=SbxpZDmQJ9L1h7rf83v6ow==.

3.      Sharma HB, Shrivastava A, Saxena Y, Sharma A. Cardiorespiratory Fitness and Heart Rate Recovery in Type-II Diabetic Males: The Effect of Adiposity. Indian J Physiol Pharmacol. 2016;60:260-7.

4.      Dominguez-Dominguez A, Martinez-Guardado I, Dominguez-Munoz FJ, Barrios-Fernandez S, Morenas-Martin J, Garcia-Gordillo MA, et al. Association between the Level of Physical Activity and Health-Related Quality of Life in Type 1 Diabetes Mellitus. A Preliminary Study. J clin Med. 2021;10:5829 doi: 10.3390/jcm10245829. 

5.      O'Brien MW, Shields CA, Dunbar MJ, Crowell SJ, Fowles JR. Physical Activity Counselling and Exercise Prescription Practices among Dietitians Across Nova Scotia. Can J Diet Pract Res. 2022;83:35-40.

6.      Brukner P, Khan K. Clinical Sports Medicine. 3rd ed. New Delhi: Tata McGraw-Hill; 2008.

7.      Lumb A. Diabetes and exercise. Clin Med (Lond). 2014;14:673-6.

8.      Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, et al. Updating ACSM's Recommendations for Exercise Preparticipation Health Screening. Med Sci Sports Exerc. 2015;47:2473-9.

9.      Holmes CJ, Hastings MK. The Application of Exercise Training for Diabetic Peripheral Neuropathy. J Clin Med. 2021;10: 5042 doi: 10.3390/jcm10215042.

10.    Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, et al. Exercise management in type 1 diabetes: a consensus statement. The lancet Diabetes Endocrinol. 2017;5:377-90.

11.    Doupis J, Karras K, Avramidis K. The Role of Individualized Exercise Prescription in Type 2 Diabetes Mellitus Management.  touchREV Endocrinol: . 2021;17:2-4.

12.    Hassabi M, Esteghamati A, Halabchi F, Abedi-Yekta AH, Mahdaviani B, Hassanmirzaie B, et al. Iranian National Clinical Practice Guideline for Exercise in Patients with Diabetes. Int J Endocrinol Metab 2021;19:e109021.

13.    Luan X, Tian X, Zhang H, Huang R, Li N, Chen P, et al. Exercise as a prescription for patients with various diseases. J Sport Health Sci. 2019;8:422-41.