Physical Activity in Diabetes

Definitions

Physical activity is defined as any bodily movement produced by skeletal muscles that result in energy expenditure.It includes all forms of activity, such as everyday walking or cycling to get from A to B, active play, work-related activity, active recreation (such as working out in a gym), dancing, gardening or playing active games, as well as organised and competitive sport[1]. Exercise is a subset of physical activity that is planned, structured, repeated and has a final or an intermediate objective to the improvement or maintenance of physical fitness[2]

Diabetes is a metabolic condition in which the body does not produce sufficient insulin to regulate blood glucose levels or where the insulin produced is unable to work effectively[3]. There are two main types of diabetes:

  • Type 1 diabetes (T1D) is an auto-immune condition in which the cells that produce insulin are destroyed so lifelong treatment with insulin is required to prevent death. It is a chronic disorder characterised by hyperglycaemia (high blood sugar) and disruption in metabolism of carbohydrates, fats, and proteins.[4] It is reported that ~5% of all Diabetes cases are Type 1 DM. [5]
  • Type 2 diabetes (T2D) accounts for at least 90% of all cases of diabetes[6]. It occurs when the body either stops producing enough insulin for its needs or becomes resistant to the effect of insulin produced. The condition is progressive requiring lifestyle management (diet and exercise) at all stages. Over time most people with type 2 diabetes will require oral drugs and or insulin. Type 2 diabetes may remain undetected for many years[7].

Epidemiology

Diabetes Mellitus (both Type 1 and Type 2) is now a global epidemic. Usually correlated with being overweight and obese, a sedentary lifestyle and familial history are also being considered as risk factors.[8] The estimated diabetes prevalence worldwide for 2011 was 366 million and it is expected to affect 552 million people by 2030[9]. The global prevalence of diabetes* among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.[10] Diabetes prevalence has been rising more rapidly in middle- and low-income countries. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. In England, 6% of people aged 17 years or older had diagnosed with diabetes in 2013[3].

A UK based study in 2004, which studied both type 1 and type 2 diabetes patients, found that only 34% of patients took some form of physical activity and only 9% of these patients exercised sufficiently to achieve a large change in heart rate or breathing[11].

Physical Activity and the Prevention of T2D

Risk of diabetes and exercise.png

There is a 30% to 40% lower risk of metabolic syndrome and type 2 diabetes in at least moderately active people compared with those who are sedentary[1].

In a study of female registered nurses aged 34–59 years at baseline, women who reported engaging in vigorous exercise at least once a week had a lower incidence of self-reported type 2 diabetes during the 8 years of follow-up than did women who did not exercise weekly[12]. Similar findings were observed between exercise and incidence of type 2 diabetes in a 5-year prospective study of male physicians aged 40–84 years[13]. Likewise, in a large cohort of postmenopausal women aged 55–69 years, the 12-year incidence of diabetes was lower in those women who reported any physical activity compared with the sedentary women[14].

Physical activity may reduce the risk for type 2 diabetes directly through improvements in insulin sensitivity[15]. This may be independent of any effect of activity on weight loss and fat distribution [15]. According to a cross-sectional population study, physical activity was shown to be negatively associated with insulin concentrations in two populations at high risk for diabetes that differed greatly by body mass index[16].

However, a large portion of the effect of physical activity in decreasing insulin resistance is short lived and may last only few days[17][18]. Thus, the consistency of an individual’s activity throughout the years is essential to ensure getting the benefits of exercise on insulin sensitivity.

Benefits of Physical Activities in Diabetes

Diabetes and exercie.jpg

Physical activity has been shown to decrease cardiovascular risk and mortality[19], in addition to improving lipid profile and endothelial function[20].

Physical activity improves insulin sensitivity[21], which is not unique to those with T2D, as patients with T1D tend to be more insulin resistant than their counterparts without diabetes[19].This effect is related to the promotion of glucose uptake in the skeletal muscles, loss of body fat in the body central part[22], the lipid products reduction and lipid oxidative capacity increase in the muscle cells,[23] the insulin function increase in the organs cells involved in the exercise, the positive regulation of signalling pathway stimulation by insulin[22] glycogen reserve decrease in liver and muscles,[24] the inflammatory markers change[24], the prevention of muscle atrophy, new muscle tissue being built and capillary network congestion increase in muscles[22] [24].

Currently, around 50% of patients with T1D are either overweight or obese. They also have higher waist and hip circumferences when compared to healthy controls[25]. Co-morbidities often associated with excess body weight, reduce the benefits of good metabolic control[26]. Thus, controlling body weight in patients with diabetes is necessary due to the well-known relationship between obesity and cardiovascular disease (CVD)[27].

Carroll &  Dudfield reported that in addition to changing Type 2 diabetic patients' life style, exercise has positive effects on weight loss, waist circumference, fasting glucose plasma and insulin serum levels[28].

The results of one meta-analysis suggest that High Intensity Training is effective at improving measures of insulin resistance compared with continuous exercise and a non-exercising control group. Importantly, the largest effects were seen in those with type 2 diabetes or metabolic syndrome. Furthermore, in those with type 2 diabetes or metabolic syndrome, there was a 0.92 mmol L−1 reduction in fasting glucose and a 0.47% (5 mmol L−1) reduction in HbA1c when compared to studies with a non-exercising control group.There was a significant reduction of 1.3 kg in body weight compared with the non-exercising control group, an effect largely observed in those described as overweight, obese, with, or at risk of type 2 diabetes. In addition, cardiorespiratory fitness improved compared with both controls[29].

Barriers to Physical Activities

Addressing perceived barriers to performing recommended PA levels in this population is crucial for planning effective PA-promoting interventions[30].

Different studies in many communities identified variable barriers. One study of barriers among Irish patients with T2D concluded the perceived boring nature of exercise, lack of time, physical pain and depression were the commonest reported major barriers to exercise, and are, therefore, the main issues that need to be overcome when attempting to increase exercise levels in obese Irish patients with T2DM[31]. Another study in Oman reported lack of willpower, low resources and low social support (especially in females) as the most common barriers to performing leisure PA[30]. Whilst fear of hypoglycaemia, work schedule, loss of control over diabetes, and low levels of fitness were identified by identified by Razeau et al[32].

Other barriers include[33]:

  • Fatigue
  • Lack self-motivation
  • Low self-efficacy
  • Fear being injured or have been injured recently
  • Lack self-management skills, such as the ability to set personal goals, monitor progress, or reward progress toward such goals
  • Barriers related to exercise facilities such as parks, sidewalks, bicycle trails or safe and convenient pleasant walking paths .

On the other hand, Perceived well-being, knowledge of insulin pharmacokinetics, implementation of strategies to reduce the probability of exercise-induced hypoglycaemia, and greater social support were associated with fewer barriers. Moreover, having someone with whom to perform physical activity was also associated with fewer barriers[34].

Promoting Physical Exercise in Individuals with Diabetes

Lifestyle changes may be difficult to undertake, especially in older adults; therefore, self-management education and support focused on general knowledge of diabetes, adherence to therapy, lifestyle changes, and self-monitoring of blood glucose are fundamental to optimise glycemic control in order to prevent or delay acute and chronic complications and to improve quality of life for people with diabetes[35][36][37].

A lot of evidence shows that educational programs addressing nutrition and training administered in the community setting for those with T2D can lead to favourable health benefits, including weight reduction, decrease of cardiovascular risk, and improved physical function, especially when these interventions include a cognitive-behavioral approach[38][39][40][37].

Several studies were carried out to investigate the role of exercise in diabetes management, and they confirmed a reduction of medication use (with a consequent decrease of costs) and an improvement of clinical, metabolic, and anthropometric parameters in patients undergoing structured community programs of supervised exercise[41][42][43]. Most of these programs showed the opportunity to combine a multidisciplinary educational intervention with a training program in order to improve the self-management of T2D and to establish durable behaviour changes[44][45][46][37].

Exercise Prescription/Recommendations

For meaningful improvements in cardiorespiratory fitness and metabolic health to occur in adults is engaging in a minimum of 150 min of moderate-intensity or 75 min of vigorous-intensity physical activity per week, accumulated in bouts of 10 min or more[29]. The guidelines for weight loss are greater, suggesting that 200–300 min per week are required for long-term reductions[29].

People with diabetes should perform aerobic exercise at moderate intensity 3 or more days per week for a total of 150 minutes minimum per week. Exercise routine should consist of a combination of aerobic and muscle strengthening training. For those who have been sedentary, these individuals should request clearance from their health care provider prior to beginning an exercise program[33].

Safe and effective exercise prescription for the individual with diabetes depends on the careful weighing of multiple factors and sound clinical judgment. Assessment of the individual’s medical history and physical examination will help determine the degree of risk and identify the most appropriate physical activity[33].

PA advice specific to Diabetes:

  1. The PA programme should consist primarily of aerobic and resistance training, as these have been shown to have clear benefits in prevention and management of diabetes and metabolic syndrome[47][48].
  2. Aerobic and resistance exercise should be performed at least three times a week; this is because the effect of exercise-induced improvements in insulin action is short-lived[49][43][48]. Most clinical trials evaluating exercise interventions in type 2 diabetes have used a frequency of three times per week, but current guidelines for adults generally recommend five sessions of moderate activity per week[48].

Physiological concerns for Type 2 Diabetes include the following:

  • When BG values are above 300 mg/dl during physical activity, hydration is important. If BG results are consistently elevated, patients should consult with their health care provider and/or diabetes specialist prior to continuing their regular exercise program[50][33].
  • Persons with type 1 diabetes should check for ketones if BG is greater than 300 mg/dl. If present, activity should be delayed, individual should hydrate and follow plan of care for elevated ketones. However, it is not necessary to postpone physical activity based simply on hyperglycaemia, provided the patient feels well and urine and/or blood ketones are trace or absent[51][33].
  • Peripheral neuropathy is a concern in regards to foot injury. Individuals without acute ulceration can participate in moderate weight bearing exercise. Careful attention to appropriate foot wear and any signs of foot damage should be emphasised[52]. Balance may also be compromised and should be evaluated due to increased risk of falls[53]. Consider consultation with a podiatrist to determine patient’s risk[33].
  • Autonomic neuropathy increases the risk of silent heart attack and hypotension. If there are unexplained symptoms and feelings of extreme fatigue which last for more than a few minutes, physical activity should be stopped and the individual should be coached to report it immediately to their health care provider. The individual may also have more difficulty adjusting to temperature extremes and should consider this when choosing a physical activity for that day[52]. Evaluation by their health care provider is appropriate and the individual may be referred to a cardiac rehabilitation program for monitoring during exercise[33].
  • Those with a history of uncontrolled proliferative retinopathy should avoid activities that increase the risk of intra-ocular pressure such as the Valsalva manoeuvre that include lifting heavy weights or jarring the head, that may occur in contact sports. In the absence of haemorrhaging, individuals can participate in moderate activity[48][33].

Exercising with Type 1 Diabetes

  • Regular monitoring of blood glucose concentrations, and trial and error is needed to understand and manage each individuals response to exercise
  • Intensity and duration of exercise
    • Pre-exercise insulin dose generally needs to be reduced when exercise extends beyond 30 minutes
    • Varies for each individual; generally, longer exercise, less insulin
  • Degree of metabolic control before exercise
    • Easier to manage and predict the body's response to exercise when metabolic control is good
    • Dangerous to commence exercise when blood glucose levels are high and ketones are present in the urine
  • Type and dose of insulin injected before exercise
    • Common practice to use a mixture of short and long lasting insulin
    • Necessary to predict the peak period of insulin activity to avoid excessive levels of insulin in the blood at the same time as exercising.
  • Site of insulin injection
    • Insulin absorption is increased in exercising muscles
    • The abdomen is usually the preferred site for insulin injection prior to exercise
  • Timing of previous meal
    • Insulin requirements are influenced by the amount and type of food consumed
  • During exercise carbohydrate
    • Blood glucose 5 to 10 mmol/l: 30 to 45 g CHO/h
    • Blood glucose 10 to 14 mmol/l: 15 g CHO/h
    • Blood glucose >14 mmol/l: no exercise

Role of the Physiotherapist

Exercise training programs have emerged as a useful therapeutic regimen for the management of diabetes mellitus. [54] Primary effects include the development of aerobic and resistance exercise programs which have been shown to decrease the incidence of T2DM. Secondary effects include the ability of aerobic and resistance training to help in the control of diabetes. There is accumulating evidence that combined aerobic and resistance exercise training is more effective than either model alone.

It is important to be aware of Hyperglycaemia, caused by a lack of glucose control, and Hypoglycaemia, caused by taking too much insulin or glucose-lowering drugs. Contra-indications to exercise are blood glucose levels >250mg/dl and <100mg/dl. Active diabetic retinopathy means no strenuous activity (jogging, stepping). Significant peripheral neuropathy is an indication to limit weight-bearing exercise. Patient who have difficulty with thermoregulation should avoid exercise in extreme environments and be vigilant about adequate hydration. Dehydration can have an effect on blood glucose levels (e.g. 500ml of fluid consumed 2hr pre-exercise). A standard recommendation for diabetic patients is that exercise induces a proper warm-up and cool-down period. A warm-up should consist of 5-10mins of aerobic activity at a low-intensity level.

A combination of aerobic and strengthening exercises should be recommended. But precautionary measures for exercise involving the feet are essential for many patients with diabetes. The overall aim of exercise prescription, as mentioned above, is to achieve the ACSM guidelines for healthy sedentary individuals. A diabetes identification bracelet or shoe tag should be clearly visible when exercising.

Resources

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