• Increase Font Size
  • Decrease Font Size
  • View as PDF

Diabetes and Physical Activity

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

To update and crystallize current thinking on the role of exercise in patients with type 1 and type 2 diabetes.

Inclusion Criteria:

None specifically mentioned.

Exclusion Criteria:

None specifically mentioned.

Description of Study Protocol:

Recruitment

Selection methods for articles not mentioned.

Design

Consensus Report.

Blinding Used (if applicable):

Not applicable.

Intervention (if applicable):

Not applicable.

Statistical Analysis 

Statistical analysis of articles not described.

Data Collection Summary:

Timing of Measurements

Consensus Report.

Dependent Variables

Consensus Report.

Independent Variables

Consensus Report.

Control Variables 

Description of Actual Data Sample:

Initial N:  Based on 6 references, including 1 technical review.

Attrition (Final N):  6 references

Age:  Not mentioned

Ethnicity:  Not mentioned

Other Relevant Demographics

Anthropometrics

Location: 

 

Summary of Results:

Other Findings

Evaluation of the Patient Before Exercise 

1. Patients with diabetes should undergo a detailed medical evaluation with appropriate diagnostic studies to screen for macro- and microvascular complications that may be worsened by the exercise program, and to allow for individualization of the exercise program.

2. Cardiovascular system:

A graded exercise test may be helpful if the patient is planning a moderate to high-intensity exercise program and is at increased risk for underlying CVD based on one of the following criteria:

  1. > 35 yrs of age
  2. type 2 diabetes >10 yr
  3. type 1 diabetes >15 yr
  4. any additional risk factor for CAD
  5. microvascular disease: proliferative retinopathy or nephropathy, including microalbuminuria
  6. peripheral vascular disease
  7. autonomic neuropathy

3. Peripheral arterial disease

Evaluation of peripheral arterial disease (PAD) is based on signs & symptoms:

Intermittent claudication, cold feet, decreased or absent pulses, atrophy of subcutaneous tissues, and hair loss.

4. Retinopathy

Eye exams are recommended yearly in those with diabetes. Joslin Clinic recommendations for physical activity in those with proliferative diabetic retinopathy (PDR) or nonproliverative diabetic retinopathy (NPDR) can be used for recommendations:

Moderate NPDR:

Discourage activities that dramatically increase

blood pressure:

  • Power lifting
  • Heavy Valsalva maneuvers

Repeat ocular exam q 4 - 6 months

Severe NPDR:

  • Discourage activities that substantially increase
  • Valsalva maneuvers, active jarring
  • Boxing
  • Heavy competitive sports

Repeat ocular exam q 2 – 4 months

PDR:

Discourage strenuous activities

  • Valsalva maneuvers, pounding, jarring
  • Weight lifting
  • Jogging
  • High-impact aerobics
  • Racquet sports
  • Strenuous trumpet playing

Activities that are acceptable

  • Swimming
  • Walking
  • Low-impact aerobics
  • Stationary cycling
  • Endurance exercise

Repeat ocular exam q 1-2 months

5. Nephropathy

Specific recommendations for patients have not been developed for decreased renal function (microabluminura >20 mg/min or overt nephropathy <200 mg/min). However, most with renal disease do not have the capacity for exercise that limits physical activity.

6. Neuropathy: peripheral (PN)

PN with loss of sensation of the feet can increase the risk for injury.

Contraindicated exercise:
  • Treadmill
  • Prolonged walking
  • Jogging
  • Step exercise

Recommended exercise:
  • Swimming
  • Bicycling
  • Rowing
  • Chair exercises
  • Arm exercises
  • Other non-weight-bearing exercise

7. Neuropathy: autonomic

Cardiac autonomic neuropathy (CAN) may be indicated by resting tachycardia >100 beats/minute, orthostasis (a decrease in systolic blood pressure >20 mmHg upon standing). Sudden death and silent MI may be the result of CAN in diabetes.

Resting or stress thallium myocardial scintigraphy is an appropriate noninvasive test for macrovascular CAD in these individuals.

Exercise and type 2 diabetes

1. Glycemic control: Regular exercise training increases insulin sensitivity and improves HbA1c by 10% - 20% in those with mild type 2 diabetes mellitus.

  • Studies used regimens at an intensity of 50% - 80% VO2max, 3-4 times/week for 30-60 minutes/session.
  • Studies with the best adherence used an initial period of supervision, followed by home exercise and frequent follow-up assessment.
  • Studies in this population lack good study design; more research needs to be done.

2. Prevention of CVD

Low levels of aerobic fitness are associated with many CVD risk factors especially in individuals with type 2 diabetes and insulin resistance syndrome.

3. Hyperlipidemia

Regular exercise is effective in decreasing TG rich VLDL.

4. Hypertension

The effects of exercise on reducing blood pressure have been demonstrated most consistently in hyperinsulinemic subjects.

5. Obesity

Exercise may enhance weight loss and weight maintenance when used along with a reduced kcal diet.

6. Prevention of type 2 diabetes

Exercise is useful in preventing or delaying the onset of type 2 diabetes mellitus.

 

Exercise and type 1 diabetes mellitus

1. Those with type 1 diabetes can participate in physical activity if they are in good glycemic control and do not have complications.

2. Exercise can improve the lipoprotein profile, decrease blood pressure, and improve cardiovascular fitness. Few studies, however, have shown an improvement in HbA1c in individuals with type 1 diabetes who participate in regular physical activity.

3. Hormonal adaptations to exercise are lost in those with type 1 diabetes. Lack of insulin can result in an excessive release of counterinsulin hormones during exercise (glucagons) and an increase in blood glucose and ketones and even precipitate ketoacidosis.

4. Recommendations for those participating in exercise:

  • Avoid exercise if fasting plasma glucose is >250 mg/dL and ketosis is present and use caution if plasma glucose is >300 mg/dL and no ketosis is present
  • Consume carbohydrate if plasma glucose is <100 mg/dL
  • Monitor blood glucose before and after exercise
  • Identify when changes in insulin or food intake are necessary
  • Learn the glycemic response to different exercise conditions
  • Carbohydrate-based foods should be readily available during and after exercise.

Exercise in the elderly

Decreases in insulin resistance in the elderly are partly due to lack of physical activity. Progressive decreases in fitness, muscle mass and strength with aging can be preventable with regular physical activity.

: : systolic blood pressure:

Author Conclusion:

The importance of promoting exercise is a vital component of prevention and management of type 2 diabetes. The benefits of physical activity are probably greatest with insulin resistance and impaired glucose tolerance. For those with type 1 diabetes, the emphasis should be on adjusting the regime of insulin and diet to allow for safe participation in physical activity.

Funding Source:
Reviewer Comments:

Very thorough review of physical activity in those with diabetes mellitus. All health professionals providing care for those with diabetes should review this article.

Quality Criteria Checklist: Review Articles
Relevance Questions
  1. Will the answer if true, have a direct bearing on the health of patients? Yes
  2. Is the outcome or topic something that patients/clients/population groups would care about? Yes
  3. Is the problem addressed in the review one that is relevant to dietetics practice? Yes
  4. Will the information, if true, require a change in practice? Yes
 
Validity Questions
  1. Was the question for the review clearly focused and appropriate? Yes
  2. Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described? No
  3. Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased? No
  4. Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible? No
  5. Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined? Yes
  6. Was the outcome of interest clearly indicated? Were other potential harms and benefits considered? Yes
  7. Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described? No
  8. Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included? Yes
  9. Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed? Yes
  10. Was bias due to the review's funding or sponsorship unlikely? Yes