impact of exercise on patients with diabetes...

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Impact of Exercise on Patients with Diabetes Mellitus

Bret Goodpaster, Ph.D. Exercise Physiologist

Assistant Professor of MedicineUniversity of Pittsburgh

Division of Endocrinology and Metabolism

Learning ObjectivesAfter completing this section, you should be able to:

1. Recommend behavioral strategies for starting and maintaining an exercise program.

2. Develop general exercise guidelines and precautions for patients with special needs and concerns.

3. Compare the effects of exercise and insulin on blood glucose utilization.

4. Assess the impact of exercise on insulin requirements.5. Discuss safety concerns for the general population as

well as identify particular safety concerns for patients with diabetes participating in exercise.

Exercise as a behavior!

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Motivation: An Important Component of Behavior Change • One of the most important motivational

factors in becoming more physically active is to better understand WHY you want to make positive, healthy changes in your life.

• Remember, there are many reasons why people decide to become and stay active.

• What’s important is that you know and believe in your own motivations for making these changes.

Self-Awareness and Self-Monitoring

• The first step in making important lifestyle changes, including physical activity, is to know how active you are currently, in other words, to become MORE AWARE of the amount of activity you are doing.

Self-Awareness and Self-Monitoring

• The best way to become more self-aware is to start SELF-MONITORINGyour activities.

• The best way to self-monitor is to WRITE DOWN or RECORD your activities every day.

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Learning ActivityBelow are questions that are related to why you want to become a more physically active person. Please take a few minutes to think about each question as it relates to you and then write down your thoughts. We will discuss your answers and how we, as a group, could help each other with our motivations for activity.

1.What are the benefits that you believe you can get from becoming more physically active?

2. What are YOUR MAIN MOTIVATIONS for wanting to become more active? Why do YOU personally want to change?

3. How can others help you in making these changes?

Excuses Individuals Give NOT To Exercise

• I do not have enough time • I need the time for my family• Work gets in the way• I am feeling too down to exercise• I am bored with exercising • I am too old

Suggestions to Overcome Some of Those Excuses

• Everyone is very busy. You have to plan to fit exercise into a busy schedule– Get up earlier to get an exercise in – Can give an

energy boost for the rest of the day– If you do not have time to fit a full 30 minutes of

exercise in, you can break down your sessions into two 15-minute sessions or three 10-minute sessions

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Suggestions to Overcome Some of Those Excuses

• Many families do have busy lifestyles. Spending time together is important, so why not do some activities as a family.

• Many people nowadays work long, hard hours–lots of stress. – Exercise can be used as a stress reliever.

• When feeling depressed or down, it is good to exercise. Exercise increases the serotonin levels in the brain.

• Getting bored – switch up your exercise routine or find an exercise partner.

• Too Old–Exercise is an ageless activity.

Goals• Negative thoughts regarding exercise may

result from setting goals that are not realistic.

• If patients feel as if they are not meeting their physical activity goals, they may need to disengage from those goals and come up with new, more realistic goals.

• This is why each time goals are set, patients should take a step back and make sure that the goal is realistic and fits well with their overall abilities.

10 Ways to Stay Motivated to Exercise

1. Write out a weekly plan–put your workout time on your to–do list

2. Pick an exercise that you like3. It is easy to make excuses – Remember why the

exercise program was started. Make your goal a priority in life

4. Think of all the positive things exercise can do for the body

5. Be patient. You will not magically see weight changes. Weight loss can be a slow process

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10 Ways to Stay Motivated to Exercise

6. Keep track of progress and reward yourself for reaching goals

7. Use exercise as a social support 8. Listen to music and books on tape as you

exercise9. Use weight or resistance bands for strength

training for part of a workout10. Plan ahead for bad weather, traveling and

house guests

Learning Activity

Here are some examples of different types of negative thoughts and how they can be modified to be positive thoughts related to realistic goals. Are any of these thoughts familiar?

Learning Activity

Negative Thought Types Some positive ways of thinking related to realistic goals.

Good or Bad- “Look at what I did. I didn’t even walk today. I’ll never get in shape.”

Create a Balance in Your Day. “I slipped up one day, tomorrow I will put my shoes by the front door to remind myself to walk”

Excuses- “Its too cold to take a walk today.” “I don’t have the will power or the energy to do this.”

Be Creative-It’s Worth a Try. “I will go walk at the mall today.” “The sooner I go for a walk the more energy I will have. It takes effort to change!”

Should- “I am sick of writing in my Physical activity log. Why am I doing thisanyway?”

Take Charge-It’s Your Health! “Completing my physical activity log will help me to self-monitor my physical activity behaviors.”

Not As Good As- “Jane walked five times this week and I only walked three times.”

I Am Not Jane! “This is not a competition. I will progress at a rate that is safe for me and in line with my goals.”

Give Up- “I cannot keep up with all this, I might as well forget it.” “I’ll never be able to be an independent exerciser.”

Reach Out to Support System- “Whenever I feel like giving up, I will call one of my social support buddies and ask for some help.”

Below are some examples of negative versus positive thoughts about physical activity. Can you think of others?

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Exercise in Patients with Type 1 Diabetes

Factors that Influence the Response to Physical Activity

• Metabolic control• Intensity• Duration• Type of exercise• Fitness level• Nutritional state• Time of last meal or snack• Timing, type, and location of insulin injection

Exercise and Insulin–Additive Effects

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Exercise Strategies in Patients with Type 1 Diabetes

• Decrease insulin peaking during exercise session

• Inject insulin in subcutaneous fat• Blood glucose should be monitored

before and after exercise• Carry carbohydrate snack while active


• Patient education is critical to increase awareness

• It may be important to avoid activity prior to bedtime

• During post activity (exercise) period– Decrease insulin peaking– Supplement carbohydrate – Monitor blood glucose frequently


Snack Guidelines for People who use Insulin• Determine pre-exercise blood glucose level• Pay attention to time of exercise in relation to

medication and previous meal• Note that type, intensity, and duration of

exercise may affect blood glucose responses• Preference for or tolerance of solid vs. liquid

carbohydrate

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Post-activity, Delayed Onset Hypoglycemia

• Hypoglycemia occurring 4 or more hours following physical activity

• Moderate to high intensity with a duration > 30 minutes

• Results from:– Increased insulin sensitivity and mobilization– Increased glucose utilization– Replenished of glycogen stores

Evidence for a Vicious Cycle of Exercise and Hypoglycemia in Type 1 Diabetes

A. C. Ertl, S. N. Davis, Diabetes/Metabolism Research and Reviews, 2004

Health–Related Quality of Life in Patients with Long-Standing Type 1 Diabetes: Benefits of Regular Physical Training

Weisenger et al. 2001

Cardiovascular fitness

Insulin requirements

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Practical Advice Regarding Exercise and Type 1 Diabetes

“Reducing pre-exercise insulin levels and adjusting carbohydrate intake prior to, during, and following prolonged moderate exercise in conjunction with close self-monitoring of blood glucose, are essential to avoid the vicious cycle of blunted counterregulatory responses to exercise and hypoglycemia. To this end, prior exposures to bouts of hypoglycemia should be minimized, and exercise should be standardized to enable the patient to understand their individual responses to a given mode, intensity, and duration of physical activity.”

A. C. Ertl, S. N. Davis, Diabetes/Metabolism Research and Reviews, 2004.

Assuring Participant Safety

• Working with trained and certified staff can help to get participants started and to maintain effective programs.

• Safe, friendly, non-threatening environment.

• Properly lighted with acceptable walking surface.


• Signs and SymptomsThink heart attack or stroke

– CHEST PAIN or DISCOMFORT– SHORTNESS OF BREATH– DIZZYIESS– WEAKNESS or NUMBNESS– SWELLING OF BOTH ANKLES– Signs can be subtle, particularly in women– Teach participants signs– Call patient’s PCP or activate EMS

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• Keep track of exercise participant’s progress.• “Since your last visit have you…

– Seen a doctor?– Changed your medications?– Experienced

• Chest discomfort or angina?• Rapid or irregular heartbeat?• Shortness of breath or dizziness?• > 4 pounds weight gain?• Swellings of both ankles?• Increase fatigue?• Any other problems?”

Assuring Participant SafetyFoot Care

• Particularly in individuals with diabetes or peripheral vascular disease

• Suggest proper footwear• Teach participants to inspect feet regularly • Recommend silica gel or air midsoles• Polyester or polyester-cotton blend socks• Non-weight-bearing exercise for individuals

with foot ulcer

Assuring Participant SafetyHypoglycemia (low blood sugar)

• Individuals with diabetes• Teach participants to self-monitor blood sugar

before and after sessions• Have sweetened beverage or snack available

for episodes of lightheadedness or hypoglycemia

• Exercise facilities to have glucometer– Be familiar with use

• Glucose < 80 mg/dL give snack and re-check. If > 100 then continue with program

• Glucose > 240 postpone session

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Exercise–Induced Hypoglycemia

• On insulin or sulfonylureas, meglitinides, nateglinide

Crossing Antarctica with Diabetes:

Taking Diet, Exercise and Diabetes Management to the Extremes

The Ultimate Walk

The NovoLog Ultimate Walk to Cure Diabetes sought to raise funds for juvenile diabetes research by trekking to the South Pole. The money raised was distributed through the Juvenile Diabetes Research Foundation and Diabetes UK to help them find a cure for Type I diabetes.

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Research Objectives of Expedition

To determine energy balance and changes in body composition, physical fitness, blood lipid profile and glucose control in a 35-year-old man with type 1 diabetes mellitus (T1DM) during a ski trek across Antarctica.

A 37-year-old man without diabetes (NOND) also completed this expedition.

The ExpeditionAmbient temperature during the 62-day trek ranged between –27oC and –5oC, and altitude steadily rose from 824 m to 2,835 m at the South Pole.

Each man pulled his own provisions on a 70 kg sledge an average of 8.9 hrs per day by skis.

The Antarctic Diet

The diet goal was:

6,514 kcals, 352 gm fat (47.6% kcals from fat)

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Type 1 diabetes Non-diabetic

ExerciseResting Non-exercise activity

5,590 Kcal/day 7,285 Kcal/day

Total Daily Energy Expenditure

Changes in Body Weight and Body Fat

0102030405060708090

100

0102030405060708090

100

Kg

FM

FFM

Pre Post0

102030405060708090

100

0102030405060708090

100

Kg

Pre Post

T1DM NONDPre Post Pre Post

Weight (kg) 87.0 75.5 94.8 76.8Fat Mass (kg) 17.0 9.3 21.1 7.9% Body Fat 19.5 12.3 22.2 10.3

Type 1 diabetes Non-diabetic

Energy Expenditure

Energy Intake

T1DM NOND

-5,590 -7,285

4,018 3,821

-1,572 -3,464 Energy Balance

Kcal/day

Positive energy balance = weight gain

Negative energy balance = weight loss

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Glucose control in a person with type 1 diabetes during extreme activity in

an extreme environment

HbA1C Pre Post 8.8 11.7

Summary

• A person with type 1 diabetes is capable of performing exceptionally demanding physical activity.

• Despite the rather large amount of energy intake, however, the high daily energy expenditure dramatically reduced body weight.

• This energy imbalance, along with the inability to more frequently monitor blood glucose in extreme conditions, likely contributed to the slightly worsening blood glucose control.

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Recommended Readings

1. A. C. Ertl, S. N. Davis, Diabetes/Metabolism Research and Reviews, 2004.

2. Devlin J, Scheider S, Kriska A: Handbook in exercise in diabetes. Ruderman N, Ed. Alexandria, VA, American Diabetes Association, 2002.

3. Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C: Physical activity/exercise and type 2 diabetes. Diabetes Care 27:2518-2539, 2004.

impact of exercise on patients with diabetes...

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