Impact of Exercise on Patients with Diabetes Mellitus Bret Goodpaster, Ph.D. Exercise Physiologist Assistant Professor of Medicine University of Pittsburgh Division of Endocrinology and Metabolism Learning Objectives After 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! 1
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 selfaware is to start SELF-MONITORING your activities. The best way to self-monitor is to WRITE DOWN or RECORD your activities every day. 2
Learning Activity Below 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 3
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 like 3. 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 4
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 exercise 9. Use weight or resistance bands for strength training for part of a workout 10. 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 Below are some examples of negative versus positive thoughts about physical activity. Can you think of others? Negative Thought Types Good or Bad- Look at what I did. I didn t even walk today. I ll never get in shape. Some positive ways of thinking related to realistic goals. 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- Be Creative-It s Worth a Try. Its too cold to take a walk today. I will go walk at the mall today. I don t have the will power or the The sooner I go for a walk the more energy I energy to do this. will have. It takes effort to change! Should- Take Charge-It s Your Health! I am sick of writing in my Completing my physical activity log will help Physical activity log. Why am I doing this me to self-monitor my physical activity behaviors. anyway? Not As Good As- I Am Not Jane! Jane walked five times this week and This is not a competition. I will progress at a rate I only walked three times. that is safe for me and in line with my goals. Give Up- Reach Out to Support System- I cannot keep up with all this, I might Whenever I feel like giving up, I will call one of as well forget it. my social support buddies and ask for some help. I ll never be able to be an independent exerciser. 5
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 6
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 Exercise Strategies in Patients with Type 1 Diabetes 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 Exercise Strategies in Patients with Type 1 Diabetes 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 7
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 Cardiovascular fitness Insulin requirements Weisenger et al. 2001 8
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. Assuring Participant Safety Signs and Symptoms Think 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 9
Assuring Participant Safety 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 Safety Foot 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 Safety Hypoglycemia (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 recheck. If > 100 then continue with program Glucose > 240 postpone session 10
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. 11
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 Expedition Ambient temperature during the 62-day trek ranged between 27 o C and 5 o C, 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) 12
Total Daily Energy Expenditure 5,590 Kcal/day 7,285 Kcal/day Type 1 diabetes Non-diabetic Exercise Resting Non-exercise activity Changes in Body Weight and Body Fat Kg 100 90 80 70 60 50 40 30 20 10 0 Pre Post Type 1 diabetes Kg 100 90 80 70 60 50 40 30 20 10 0 Pre Post Non-diabetic FFM FM T1DM NOND Pre Post Pre Post Weight (kg) 87.0 75.5 94.8 76.8 Fat Mass (kg) 17.0 9.3 21.1 7.9 % Body Fat 19.5 12.3 22.2 10.3 Negative energy balance = weight loss Positive energy balance = weight gain Kcal/day T1DM NOND Energy Expenditure -5,590-7,285 Energy Intake 4,018 3,821 Energy Balance -1,572-3,464 13
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. 14
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. 15