1. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 9 Exercise for Those with Diabetes

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

3. 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/dL is normal 140–199 mg/dL suggests prediabetes ≥200 mg/dL indicates diabetes

4. 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/dL suggests diabetes if the patient also complains of frequent urination, excessive thirst, and unexplained weight loss –Follow with FPG or OGT test to confirm

5. 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

6. 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

7. 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

8. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Effects of insulin on muscle, liver, and fat cells

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

10. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Negative feedback loop for insulin and glucagon

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

12. 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

13. 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

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

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

16. 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

17. 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

18. 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

19. 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 2R (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

20. 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

21. 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

22. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Other special considerations (cont'd) Check blood glucose levels before exercising –If <100 mg/dL, consume small amount of carbohydrates –If 100–250 mg/dL, begin exercise –If >250 mg/dL, 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

23. 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

24. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tips for the diabetic exerciser

25. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins When diabetics should avoid exercise

26. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sample exercises Upper body –Chest press –Lateral pull-down –Seated row –Shoulder press –Biceps curl –Triceps dip

27. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Sample exercises (cont’d) Lower body –Leg press –Squats –Lunges –Leg extension –Leg curl

28. Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

29. 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

30. 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

31. 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

32. 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

33. 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