Exercise and Activity Goals To understand the benefits of an exercise program To plan a program that balances exercise, food intake, and in some instances, diabetes medications Your objectives 1. List three potential benefits of exercise. 2. Name three endurance activities. 3. Describe the three parts of an exercise program. 4. List three recommendations when planning exercise. 5. Choose to incorporate exercise into lifestyle. Additional objectives for those taking insulin 6. State the effect of exercise on blood glucose. 7. State the effect of exercise on insulin absorption. 8. State two instances when you should not exercise. 9. State how to avoid low blood glucose levels during unplanned planned activity. Pre-study questions: (circle the correct answer) 1) A regular exercise program: a) Helps with weight control b) Decreases the need for food c) Causes heart problems 2) Exercise should be: a) Done right before sleeping b) Done regularly c) Limited to one time per week 3) A potential benefit of exercise is: a) Decreased flexibility b) Improved diabetes control c) Injured joints 4) It is best to exercise: a) When the blood glucose is very high b) When I am alone c) At the same time each day
Pre-study questions for those taking insulin: (circle the correct answer) 5) To avoid low blood glucose, the best time of day to exercise is: a) When insulin is not peaking b) At bedtime c) When insulin is peaking 6) Your blood glucose level before exercise is 320 mg/dl. You should: a) Exercise vigorously to help lower the blood glucose b) Avoid exercise c) Eat a snack before exercising 7) At 2 p.m., your friends invite you to play tennis at 3 p.m. You should: a) Decline, it will be a hassle b) Check your blood glucose level and take a snack if needed before tennis c) Take additional insulin since your blood glucose is probably elevated 8) You want to play tennis at 7 p.m. You could: a) Decrease the insulin dose taken before exercise b) Increase the dose following exercise c) Eat a smaller evening meal Diabetes and exercise considerations Exercise is of benefit to all, but it is of special value to those with diabetes. Regular exercise helps you lose weight, maintain your proper weight and control your blood glucose. In some cases, regular exercise can result in a need for less diabetes medication while still maintaining good control. Exercise increases the body s sensitivity to insulin. It causes the exercising muscle to use more glucose, which reduces the level of glucose in the blood. However, if your blood glucose is greater than 300 mg/dl, exercise can raise your blood glucose further. When the blood glucose is very high (300 mg/dl or higher), exercise causes your body to release or produce extra glucose and not enough insulin is available to use it. Do not exercise if your blood glucose is greater than 300 mg/dl or if you are ill. Because each person exercises differently, it is impossible to predict changes in the blood glucose levels. Check and record your blood glucose level before and after exercise. By observing your blood glucose pattern, you will learn what changes in your diabetes medication or diet may be needed. General recommendations for exercise 1. Check with your physician before beginning an exercise program. 2. Do not omit your diabetes medication unless instructed to do so by your healthcare provider.
3. Carry a carbohydrate snack with you. 4. Stop exercising immediately and call your physician if you experience pain in your chest, teeth, jaw or arm, or if you have an irregular heart rate. 5. Wear proper and well-fitting shoes. 6. Exercise at the same time of the day to promote the best diabetes control. 7. Do not drink alcohol immediately before or after exercise. 8. Exercise with a friend. 9. Ask your healthcare team for more specific guidelines. Exercise and oral diabetes medication If you take oral diabetes medications, strenuous exercise may cause your blood glucose level to decrease. By preparing for this, you can prevent low blood glucose. If you are planning a long or strenuous activity (a long bicycle ride, golfing or yard work), you may need to prepare by eating one to three carbohydrate exchanges (examples: crackers, cereal, fruit, milk). Regular planned exercise, such as a walking program, does not require extra food. Avoid exercising immediately before a meal. Test your blood glucose before, during and after exercise to note any changes in the values. Do not exercise if your blood glucose is greater than 300 mg/dl or if you are ill. If your blood glucose is low before exercise, eat more food 15 to 20 minutes before you exercise. Eat food at 30-minute intervals during prolonged exercise. Routine exercise may improve your glucose control. If your test results show a decrease, contact your physician or diabetes nurse for help in changing your diabetes treatment plan. Exercise and insulin If you take insulin, be aware that exercise can affect insulin action. If you exercise when your insulin is peaking, you are more likely to have a low blood glucose reaction. Plan to exercise when your insulin is not working its hardest. You can do this by taking less insulin, eating more food at a meal or adding a snack before you exercise. Exercise also can affect insulin absorption. If you inject your insulin into a limb that is being exercised, the insulin is absorbed more quickly. For example, if you inject the insulin into your leg, and then cycle or walk, the insulin will be absorbed more quickly. Abdominal injections are recommended because they reduce this effect. During strenuous exercise, your blood glucose level may drop too low, causing an insulin reaction. By preparing for this, you usually can avoid severe reactions. When exercising for one hour or less, eat an extra quick- acting carbohydrate, such as one fruit exchange, before you start. For longer activities, such as cross-country or downhill skiing or long bicycle rides, eat one to three carbohydrate exchanges (starch, fruit or milk) before the activity, and one carbohydrate exchange every 30 to 60 minutes during the activity. This will help prevent hypoglycemia (low blood glucose) from occurring.
If you know ahead of time when you will be exercising, decrease your insulin instead of or as well as taking extra food. Which insulin you decrease will depend on the type of insulin program you are on. To make these decisions, you need to understand when each insulin you take is working best or peaking. Your healthcare team will review your specific program in greater detail with you. Test your blood glucose before, during and after exercise to note any changes in the values. Do not exercise if your blood glucose is greater than 300 mg/dl or if you are ill. Inject insulin into areas you do not use during exercise. Use your abdomen for injections. If your blood glucose is low before exercise, eat more food 15 to 20 minutes before you exercise. Eat food at 30-minutes intervals during prolonged exercise. Routine exercise may improve your glucose control. If your test results show a decrease, contact your physician or diabetes nurse for help in changing your diabetes treatment plan. Dietary guidelines during activities General Exercise Information In this booklet, the words aerobic, endurance, and conditioning are used interchangeably. Aerobic activities require oxygen provided by the lungs and cardiovascular system to the muscles and involves continuous, rhythmic contracting of the major muscle groups. The heart of your aerobic exercise program will consist of activities such as walking, cycling, swimming, jogging or aerobic dance. These are endurance activities that do not require excessive speed. Other activities designed to increase
muscle strength and tone can be of benefit and may be prescribed, but should not replace the endurance exercise. Potential benefits of regular exercise include: Increased endurance capacity and greater ability to perform physical and mental work Less fatigue, tension and anxiety Improved joint function A desirable rate of fat weight loss if combined with a moderate reduction in food intake Lower risk of developing cardiovascular disease Lower risk of developing osteoporosis (thin bones) Decrease in cigarette smoking Improved appearance and a sense of well-being Exercise may improve certain cardiovascular disease risk factors such as obesity, high blood pressure, elevated blood fats and sugar, and feelings of tension and anxiety. Also, people who begin exercise programs often report that they feel better than when they were inactive. Before you begin an exercise program or make major changes to an existing exercise routine, check with your physician. For people over 30 years old who have diabetes, a graded exercise test with heart monitoring is usually advised. This helps ensure that the heart and circulation will respond normally to exercise. In addition, exercise test results can be used to plan a personalized exercise program. The human body is designed so that if you put forth a little more physical effort than usual, it responds by improving its capacity for exercise. By gradually increasing the amount of exercise, and allowing the body to adapt, you can improve your fitness level in eight to 12 weeks. It is important to realize that very strenuous exercise is not required to improve fitness. A moderate amount of exercise is sufficient and will be more enjoyable for most people. Basic stretching exercises for warm-up and cool-down A few simple guidelines will make stretching more enjoyable and beneficial. Stretch to the point that you feel a definite pulling sensation in the muscle group involved, but do not strain. Stretching should not result in pain. When performing the exercises, do not bounce rhythmically, but hold the position for 30 seconds, and then repeat with the other leg. These exercises may be repeated twice. As you hold the position, consciously try to relax the muscles being stretched.
1. Calf Stretch Starting position: Stand an arm s length away from a wall and rest your forearms on the wall with your forehead on the back of your arms. Point your toes straight ahead. Bend your right knee and bring it toward the wall. Keep your left leg straight with the heel on the floor. Movement: Slowly move your hips forward, keeping your back straight and heel on the floor until you feel a stretch in your left calf muscles. Hold this position for 30 seconds and then repeat with your other leg. 2. Thigh Stretch Starting position: Stand and place your left hand on a wall, a desk, etc., to aid in balance. Reach behind you and hold onto your right foot or ankle from the outside with your right hand (can be performed sitting). Movement: Slowly pull your right foot toward your buttocks until you feel a stretch in the front thigh muscles. Keep the knee pointing down. Hold this position for 30 seconds and then repeat with the left leg (and left hand). If you cannot reach your ankle, you can grasp the cuff of your slacks.
3. Hamstring Stretch Starting Position: Sit on the floor with your right leg extended straight forward and toes pointing toward the ceiling and foot relaxed. Bend your left knee and place the sole of your left foot on your inner right thigh. Movement: Bend forward at the waist and slowly move both hands down the right leg until you feel a stretch in the back thigh muscles (hamstrings). Keep the knee straight. Hold this position for 30 seconds and then repeat using the left leg. Note: This stretch can be performed while sitting in a chair with leg on another chair or on the edge of a bed. Conditioning exercise The endurance exercise portion of your program may include any activity that requires continuous rhythmic muscle contraction of the legs and possibly the arms Find an activity that you enjoy Examples of endurance activities include walking, cycling, jogging, swimming, cross country skiing, rowing, rope skipping, dancing and racket sports. Specific forms of exercise will be recommended for you, taking into account your preferences and physical condition. These activities are referred to as aerobic forms of exercise since they require a continuous supply of oxygen from the lungs, heart and circulatory system. The positive effect of heart and lung (cardiovascular) fitness is the same for any of these activities if they are matched in terms of three factors exercise intensity, duration and frequency. For example, you might choose to perform a lower intensity activity five times a week as compared to a higher intensity activity three times a week.
Intensity At its proper intensity, exercise will cause favorable fitness changes without being too strenuous. A proper exercise intensity requires 50 to 80 percent of the maximum endurance exercise capacity. Three tools are available to help you determine the desirable range of exercise intensity for you: heart rate or pulse, ratings of exertion and talk test. Heart rate or pulse There is a direct relationship between heart rate and increasing work load for aerobic forms of exercise. This is illustrated by the following figure. The harder you exercise, the higher your heart rate or pulse climbs until the maximum heart rate for the body is reached. Maximal heart rate tends to decrease with increasing age and is affected by cardiovascular disease and by some cardiovascular medications. Regular exercise does not influence maximal heart rate. Your physician may prescribe a target heart rate range for you that will correspond to 50 percent to 80 percent of your capacity for endurance exercise. Your target heart rate is lower than your maximum heart rate. The target heart rate is the rate necessary to result in an increase in cardiorespiratory fitness. There are several different techniques used to calculate the target heart rate and are based on your fitness level, age, and personal interests in an exercise program. The target heart rate calculation gives a heart rate that will fall somewhere within the 50 percent to 80 percent range of your exercise capacity. Some people with very irregular heart rates cannot use the heart rate method to regulate exercise intensity. In order to use heart rate as a guide for proper exercise intensity, you must be able to count your pulse during an exercise session. To feel your pulse, place two fingers (not your thumbs) on the side of your wrist over the radial artery and press gently (see figure 2). When taking your pulse during an exercise session, follow these three steps. Stop exercising and find your pulse. Count your pulse for 10 seconds.
Multiply the number you count by six to calculate the rate for one minute. To avoid feeling light-headed due to pooling of blood in the legs after exercise, shift your weight from foot to foot if you count your pulse while standing. Ratings of exertion Perceived exertion is another excellent tool to help you determine if you are exercising at a satisfactory intensity. Perceived exertion is the total amount of physical effort expended. Ratings between 11 and 15 on the scale are generally recommended. A rating of 13 generally corresponds to 70 percent of the maximum exercise intensity and would be considered near ideal for most people. Ask your physician what your range of exertion should be. The scale takes into account all feelings of exertion, physical stress and fatigue. When using the rating scale, do not focus on any one factor such as leg discomfort or labored breathing. Instead, try to concentrate on your total inner feeling of exertion. A rating of six indicates the lowest level of exertion, such as sitting comfortably in a chair. A rating of 20 reflects a maximum effort, for example, walking briskly or jogging up a very steep hill. Perceived Exertion Scale 6 7 Very, very light 8 9 Very light 10 11 Fairly light 12 13 Somewhat hard 14 15 Hard 16 17 Very hard 18 19 Very, very hard 20 Talk test During an exercise you should be able to carry on a conversation without being short of breath. If you cannot do this, you are probably pushing too hard and should slow down your pace. In general, if your exercise heart rate (pulse) or perceived exertion rating is below the level recommended for you, you may increase your intensity. If your heart rate or exertion level is above the recommended level, you should reduce your intensity. High-intensity exercises do
not produce many additional fitness benefits and increase the risk of muscle or joint soreness or injury. Discomfort should not result from a moderate exercise program. However, you should stop exercising and consult your physician if you develop chest discomfort or pressure, severe shortness of breath, bursts of very rapid or slow heart rate, irregular heart rate, excessive fatigue, marked joint or muscle pain, and dizziness or fainting. As you exercise the metabolic rate (the rate at which the body expends energy) increases. During exercise, healthy young people can increase their metabolic rate about 10 to 15 times over resting levels. We use the term resting metabolic rate (MET) to compare various forms of exercise in terms of energy expenditure. Metabolic rate at rest is termed one MET. If you exercise at an intensity that would require three times resting metabolism for energy production, that activity is said to require three METs. A chart is provided listing the average MET levels for various activities. Using the chart, you will be able to select activities which are comparable in terms of energy expenditure. Average calorie expenditures for both 120- to 130-pound and 170 to 180-pound people are also included in the table.
Frequency You should exercise at least three nonconsecutive days a week. Exercising four or five days a week will increase the rate of fitness improvement and help speed weight (fat) loss. Ask your healthcare provider how often you should exercise. Exercising more than five days a week may be done if weight loss is the primary goal. Reduce your exercise intensity if you exercise more than five days a week to reduce the risk of injury. Duration Conditioning exercise should continue for at least 20 to 30 minutes. Duration may be increased to 45 to 60 minutes if a faster rate of progress or weight loss is desired. By increasing exercise duration, you may decrease exercise intensity and still reap the fitness benefits. Thus, if you find that lower intensity exercise is more enjoyable, you may want to increase exercise duration beyond the usual 20 to 30 minutes. Getting started It is extremely important to change exercise habits gradually. If you have not been physically active in the previous two months, start the conditioning exercise component of your program conservatively. You may perform the stretching exercises and other warm-up procedures without modification. The first two to three weeks should include an exercise intensity at the lower end of your heart rate and perceived exertion recommended ranges. Exercise session duration should be 10 to 15 minutes three times a week. Increase duration one to five minutes every other session, as tolerated. Gradually increase exercise intensity only after you achieve the desired duration of exercise. Allow yourself a month or so to adapt to your individual exercise program. Cool-down This is the period immediately following the conditioning exercise. The purposes of cooldown are to gradually return your heart rate to the pre exercise level, to prevent blood from pooling in the legs which may cause dizziness, and to stretch the muscles that have been used in the endurance activity. The first two objectives are accomplished by performing three to five minutes of low level activity such as slow walking or cycle pedaling with little effort. This should be followed by the stretching activities outlined in the warm-up section which will help relax muscles, improve or maintain flexibility and help prevent soreness. The cool-down period usually takes five to 10 minutes. Special Considerations Clothing Your choice of clothing depends on the activity and the weather or place where you exercise. It is better to under-dress than to overdress because exercise will increase your body temperature. In cool weather, wear clothing in layers so you can remove or replace layers as you warm-up and cool-down.
Do not wear rubberized suits or other clothing designed to increase sweating. These garments restrict the cooling effect of evaporating sweat and can lead to dangerously high body temperatures. Also, the weight loss when these garments are worn is mostly water and will be replaced when you drink. Wear quality, well-fitting walking or jogging shoes when exercising. Visit a store with an athletic shoe department and talk with a knowledgeable salesperson before buying a pair of shoes. Environmental When you exercise on warm or humid days, more blood will flow to your skin to help cool your body. Less blood will be available for your muscles, and your heart rate will increase in response. You will find that you must decrease your exercise intensity to remain within your target heart rate and perceived exertion range. Let your heart rate and physical sensations be the guiding factor to reducing your intensity. On hot days, exercise during a cooler time of the day (morning or evening) or indoors and drink plenty of water. Drink water before and after exercise in warm, humid weather. If you exercise more than 30 minutes drink a few additional ounces of water every 15 to 20 minutes during exercise. In extremely cold, windy weather, exposed skin may freeze (frostbite). Cover exposed skin as much as possible if you must exercise outdoors. Be careful about falling and injuring yourself when walking or jogging during snowy and icy weather. For people with asthma or angina (heart pain), exercise in the cold may worsen symptoms. A scarf or mask over the nose and month during exercise will warm the inhaled air and help prevent this problem. Exercising in an indoor facility might be an alternative. On the positive side, breathing extremely cold air does not injure the lungs because the air is warmed to body temperature before it arrives in the lungs. Travel from near sea level to moderate altitude (5,000 to 10,000 feet) will decrease your endurance slightly. The reduced air pressure at higher altitudes makes less oxygen available in the air. This small reduction in exercise capacity should not keep you from exercising unless you feel ill (acute mountain sickness). When at high altitudes, you will probably need to reduce your exercise intensity slightly to remain in your targeted heart rate and exertion range. Air pollutants such as ozone and carbon monoxide may constrict the bronchial tubes in the lungs and decrease the amount of oxygen transported to the muscles by the blood. During ozone alerts or days when the air quality is poor, avoid outdoor activity, especially if you have respiratory disease. illness or time away from the exercise program If you are ill, rest and allow time for recovery. Do not exercise if you are ill. If you miss more than two or three consecutive exercise sessions, start back in the program at a lower exercise
intensity and duration. The benefits gained from an exercise program will begin to reverse themselves after only one or two weeks of inactivity. Return to your usual stage of activity as soon as you can do so comfortably. Enjoyment In order to be successful in maintaining the exercise habit, the following tips may prove useful. Choose exercise activities which you enjoy since no single form of aerobic exercise is best. Use the exercise sessions as your private time for contemplation and solitude if you are comfortable exercising alone. Consider taking an exercise class or exercising with a friend, spouse or other family member if you enjoy company during exercise, or if you think you may need help in continuing with your exercise habit. Make appointments with your self or a partner for exercise sessions as an incentive to continue with the program. Use an exercise log book to keep a record of your progress. Change the type of activity you do periodically to keep your interest for exercise. Watch television or listen to music or self-improvement audio or video tapes if you use a stationary cycle, rowing machine or some other indoor exercise device. When traveling, keep your exercise program going by walking wherever possible, and by using hotel exercise facilities such as swimming pools and fitness equipment. Answers to frequently asked questions 1. Is there a best time of day for exercise? It is recommended not to exercise for at least one hour after eating a heavy meal because of the gastrointestinal system s high demand for blood during digestion. Because exercise increases alertness, exercising immediately before bedtime may make falling asleep difficult and is not recommended. By exercising first thing in the morning, you can complete your exercise session before your day s busy schedule begins. Noontime exercise sessions break up the day s routine and can be an important weight control aid (helps avoid heavy lunches). Exercising in the early evening after completing the day s activities may help you relax and unwind in a positive way. To encourage the habit of regular exercise, consider scheduling exercise sessions at the same time of day. 2. What can I do to avoid exercise-related injuries? Performing too much exercise too soon (overuse) is the most common cause of exerciserelated aches and pains. You can minimize your risk of injury by beginning an exercise program conservatively and by progressing gradually in duration and intensity. Doing nonweight bearing activities (cycling, swimming, rowing) rather than weight-bearing
exercise (running or jumping-type activities), which emphasize repetitive pounding ), will reduce your risk of injury. 3. What is the best form of aerobic exercise? There is not one premier aerobic activity. As long as aerobic activities (walking, jogging, cycling, swimming, aerobic dancing, rowing, racket sports, etc.) are matched in terms of equal intensity, duration and frequency, the fitness and health-related benefits are very similar. 4. How many calories are expended during exercise? This question is often asked in reference to control of body weight. The combination of moderate exercise and prudent eating habits is a proven weight control prescription. Your goal should be to achieve fat loss, not necessarily body weight loss. The number of calories expended during exercise depends upon the exercise intensity and duration and the size of person. Refer to the table Energy Expenditure of Selected Activities in this booklet. Larger people expend more calories than smaller people during weightbearing forms of activity. Most people are able, once a moderate level of conditioning has been achieved, to expend 300 calories during a 30-minute exercise session. By exercising four sessions a week (300 calories each), and by decreasing calorie intake by 325 calories a day, a one-pound fat loss a week will occur. One pound of fat equals 3,500 calories. 5.1 want to begin a jogging program. How should I start? Jogging can be an enjoyable form of aerobic exercise, but it is not for everyone. In general, an exercise capacity equal or greater than 10 METs (as measured during your graded exercise test) is recommended before attempting a jogging program. People with cardiovascular disease should receive permission from
a physician before starting such a program. If you have been physically inactive (no regular exercise) for several months, start with a walking program. When you are able to walk two miles in 30 minutes (4 mph pace) comfortably, try alternating jogging and walking (jog for one minute or more and then walk for one minute, etc.). Warm-up before jogging and end with a cool-down period. Increase one step in the Starter Jogging Program every two to seven days as tolerated. In order to minimize potential muscle and joint discomfort, do not jog more than three to four sessions per week on alternate days. Jog at a comfortable pace and walk briskly, keeping within the guidelines of your perceived exertion and target heart rate range. Be sure to wear proper jogging shoes. Replace the shoes regularly before the soles are worn. 6. How can I find the time for an exercise program? Most people do not need to exercise daily. (Exceptions to this include people with heart problems, people with very limited exercise capacities, people who have diabetes, and people who need to lose a large amount of fat weight.) Three, 30-minute exercise sessions on alternate days a week will result in substantial fitness benefits for most people. Consider exercising once on the weekend with two exercise sessions during the week. By managing your time wisely and exercising on a consistent schedule, you will be successful in your program. You can save time by not traveling excessive distance to an exercise facility. 7. My family seems to want to interfere with my exercise program and keep me from doing what I know I m supposed to do. How can I help them understand that I need to take time for regular exercise? You have the ultimate responsibility for your fitness and health. However, support from your family can make the difference in the success and enjoyment of your exercise program. You can improve their cooperation by educating them about the benefits of regular physical activity. Call upon the Cardiovascular Health Clinic staff to help you provide this information to your family. You may wish to actively involve your family members in your exercise program as a means of increasing their understanding and cooperation.