Diabetes Mellitus 1. Diabetes Mellitus Glucose Management 2. Type I Diabetes Mellitus 3. Type II Diabetes Mellitus 4. Insulin Resistance Syndrome 5. Diabetes Mellitus Education 2. Definition 1. Metabolic disorder of carbohydrate economy 2. Deficiency of pancreatic beta cell Insulin secretion 3. Resistance to Insulin effect peripherally 3. Epidemiology (U.S. statistics for 2004 per ADA) 1. Prevalence 1. Type I Diabetes Mellitus: 750,000 2. Type II Diabetes Mellitus: 13 million 3. Gestational Diabetes: 135,000 4. Undiagnosed with diabetes: 5.2 million 2. Incidence 1. Type 1: 30,000 new cases per year 2. Type 2: 850,000 new cases per year 3. Gestational Diabetes Mellitus: 4% of all pregnancies 4. Fastest growing groups 1. Ages 30 to 39 years 2. Type II Diabetes in children 4. Types 1. Type I Diabetes Mellitus 1. Juvenile Diabetes Mellitus 2. Insulin Dependent Diabetes Mellitus (IDDM) 2. Type II Diabetes Mellitus 1. Adult onset Diabetes Mellitus 2. Non-Insulin Dependent Diabetes Mellitus (NIDDM) 3. Pediatric Type II Diabetes Mellitus (Pediatric NIDDM) 4. Maturity onset Diabetes of youth (MODY) 5. Symptoms 1. Classic (75% of cases of Type I Diabetes Mellitus) 1. Polyuria or nocturia 2. Polydipsia 3. Unexplained Weight Loss 2. Other symptoms 1. Increased appetite 2. Blurred vision 3. Frequent Urinary Tract Infections 4. Frequent yeast infections 5. Fatigue 6. Dry or pruritic skin 7. Numbness or tingling in the extremities
6. Diagnostic Criteria 1. Random Serum Glucose 1. Serum Glucose over 200 mg/dl with symptoms 2. Fasting Serum Glucose 1. Serum Glucose exceeds 126 mg/dl on 2 different days 3. Postprandial Glucose (2 hours post meal) 1. Serum Glucose over 200 mg/dl 2. Precedes fasting glucose increase 3. More predictive of Diabetes Mellitus Complications 4. Casual Plasma Glucose (random glucose) 1. Same criteria as postprandial glucose 5. Oral Glucose Tolerance Test (OGGT) 1. Two hour Glucose Tolerance Test (75 gram) >200 mg/dl 2. Consider in patients with Insulin Resistance 1. Patients with pre-diabetes to qualify for education7. Other monitoring 1. Home Serum Glucose monitoring 1. Over 50% of values should fall in target range8. Management: Severe Hyperglycemia at diagnosis 1. Start Insulin at onset if severe hyperglycemia 2. Criteria 1. Blood Glucose >300 mg/dl 2. Hemoglobin A1C >9.0 3. Protocol based on Urine Ketones 1. Urine Ketones positive 1. Evaluate for Diabetic Ketoacidosis 2. Check Metabolic panel and Serum Ketones 2. Urine Ketones negative 1. Type I vs Type II is not critical initially 1. Both get Insulin at this hyperglycemia level 2. Type II suspected 1. Consider adding Metformin 2. Insulin can likely be weaned later 1. Glucose toxicity causes low Insulin level 2. Endogenous Insulin will later normalize 2. Start LantusInsulin at 10 units SQ today 1. Low risk of Hypoglycemia 3. Teach glucose testing, Insulin injection today 1. Formal Diabetic Education within 1 week 2. Consider endocrinology consultation later 4. Give prescriptions today 1. Meter, strips, lancets, Insulin, syringes9. Management: Initial Education 1. Key Topics
1. See Diabetes Mellitus Glucose Management 2. See Diabetes Mellitus Education 2. Type specific Diabetes Information 1. See Type I Diabetes Mellitus 2. See Type II Diabetes Mellitus 3. Adjunctive Management 1. See Hypertension in Diabetes Mellitus 2. See Coronary Artery Disease Prevention in Diabetes 3. Tobacco Cessation 4. Weight loss 5. Aspirin in all diabetic patients 6. Consider ACE Inhibitor in all diabetic patients 1. Use low dose (2.5 to 5 mg) in normotensive patient 7. Lipid disorders 1. See Coronary Artery Disease Prevention in Diabetes 2. See Low Fat Diet 3. See AntiHyperlipidemicExercise in Diabetes Mellitus 1. See Also 1. Diabetes Mellitus 2. Exercise 2. Benefits of Exercise in Diabetes Mellitus 1. Exercise lowers Serum Glucose 1. Benefits Type I Diabetes Mellitus 2. Benefits Type II Diabetes most significantly 2. Exercise augments Insulin effect 1. Facilitates glucose transport across cell 3. Exercise reduces heart disease and stroke risk 1. Increases HDL 2. Lowers LDL 3. Lowers Total Cholesterol 4. Decreases SBP and DBP 4. Exercise improves general wellness 1. Increases self esteem 2. Improves socialization 3. Risks of Exercise in Diabetes Mellitus 1. Hypoglycemia 1. Use caution in Scuba Diving 2. Use caution in rock-climbing 3. Use caution in long-distance swimming 2. Retinopathy
1. Avoid weight lifting 2. Avoid mountain climbing 3. Neuropathy 1. Avoid weight bearing Exercises 2. Choose stationary bike or water sports 4. Autonomic Dysfunction 1. Abnormal hemodynamic response to Exercise 1. Inappropriate Heart Rate response 2. Inappropriate Blood Pressure response 2. May not experience Anginal symptoms with Exercise 3. May not experience hypoglycemic symptoms 5. Diabetic Nephropathy 1. Avoid Resistance Training 6. Cardiovascular disease 1. Consider Stress Testing prior to Exercise program4. Starting Exercise 1. Evaluate coronary, nephropathy, Neuropathy, retinopathy 1. Confirm no contraindications to starting Exercise 2. Goal energy expenditure (See METS) 1. No weight loss intended: 1000 KCal/week 2. Weight loss intended: 2000 KCal/week 3. Progressive Resistance Training 1. Low resistance (40-60% of 1 repetition maximum) 2. Low intensity 3. Gradually increase to 15-20 repetitions5. General Exercise Tips in Diabetes Mellitus 1. Preparation for regular Exercise 1. Check feet for lesions related to Exercise 2. Pre-Exercise evaluation (consider Stress Test) 3. Medic-Alert tag 4. Exercising diabetics must use Glucometer 5. Pre-planned strategy for Hypoglycemia 6. Evaluate Exercise Energy Expenditure (METS) 2. Time Exercise appropriately 1. Avoid late-evening Exercise in Type I Diabetes 2. Aerobic Exercise recommended 6 to 7 days per week 1. Duration: 20 to 60 minutes 2. Level: 60-80% of maximum Heart Rate 3. Allow time for warm up and cool down 1. Reduces injury risk 2. Reduces post-Exercise arrhythmia risk6. Blood Sugar Management 1. Check pre-Exercise blood sugar 1. Blood sugar <100 mg/dl 1. Snack 15-20 grams carbohydrate before Exercise 2. Blood sugar 100 to 250 mg/dl
1. No snack needed 3. Blood sugar >250 with ketones (or >300 without) 1. Delay Exercise 2. Check Serum Ketones 3. Treat hyperglycemia and dehydration 2. Pre-ExerciseInsulin 1. Take Insulin more than 1 hour before Exercise 2. Inject Insulin into a non-exercising site 1. Absorption at abdomen is fastest and most reliable 3. Decrease short-acting Insulin before Exercise 1. Decrease 30% for Exercise less than 1 hour 2. Decrease 40% for Exercise 1-2 hours 3. Decrease 50% for Exercise over 3 hours 3. Decrease risk of Hypoglycemia 1. Avoid Exercise during times of peak Insulin activity 2. Consider HumalogInsulin 3. Insulin injection site may affect absorption rate 4. Avoid Sulfonylurea 4. Be aware of your own blood sugar response to Exercise 1. Pre-Exercise Food 1. Meals should be ingested 1-2 hours before Exercise 2. Strenuous or prolonged Exercise 1. Start increasing calorie intake 24 hours before 2. Supplement carbohydrates every 30 minutes during 2. Supplement during Exercise with glucose solutions 1. One bottle for each 30 minutes strenuous Exercise 3. Replenish glycogen stores after Exercise 1. Based on Exercise duration and intensity 2. Be aware of delayed Hypoglycemia 5. Carry an activity pack while exercising 1. Personal identification 2. Mobile phone 3. Adequate water and carbohydrate source 4. Blood Glucose monitor7. Complications: Post-ExerciseHypoglycemia 1. Delayed Hypoglycemia 1. Occurs 6 to 28 hours after strenuous Exercise 2. Occurs despite normal blood sugars during Exercise 3. Occurs regardless of age or illness severity 4. Often occurs at night 2. Mechanism 1. Glycogen stores depleted and not replenished 2. Increased Insulin sensitivity post-Exercise8. Resources 1. Diabetes, Exercise and Sports Association 1.
2. Mountains for Active Diabetics (extreme sports) 1. http://www.mountain-mad.org 9. References 1. Whaley (2006) ACSMs Guidelines for Exercise 2. White (1997) Lecture: AAFP Sports Medicine, Dallas 3. Baraz (1994) Clin Diab 12(4):94-8 4. Fahey (1996) Am Fam Physician 53:1611-7 5. Landry (1992) Clin Sports Med 11:403-18Diabetic Education 1. Approach: Employ a Pediatric Diabetes Team (Essential) 1. Physician 2. Nurse or Nurse Practitioner 3. Diabetes Educator 4. Nutritionist or Dietician 5. Social Worker 6. Psychologist 2. Approach: Initial Education 1. Describe Diabetes Mellitus pathophysiology 2. Management principles 1. Taking Insulin (when prescribed) is non-negotiable 2. Other issues are negotiable 3. Insulin action and use 4. Blood Glucose Monitoring 5. Urine Ketone testing 6. Hypoglycemia 7. Exercise in Diabetes Mellitus 8. Nutrition in Diabetes Mellitus 9. Psychological Issues 10. Home Treatment 3. Approach: Ongoing Education 1. Should occur at every visit 2. Must be age and education-level appropriate 1. Include children age 5 and older in discussion 3. Include skill review 4. Prevention 1. Seasonal illness prevention 2. Immunizations: Influenza Vaccine 3. See Diabetic Foot Care 4. See Exercise in Diabetes Mellitus
5. See Nutrition in Diabetes Mellitus 5. Emergencies 1. Hypoglycemia 2. Type I Diabetes Mellitus Hyperglycemia 1. Diabetic Ketoacidosis (DKA) 3. Type II Diabetes Mellitus Hyperglycemia 1. Hyperosmolar Hyperglycemic Nonketotic Coma 6. Chronic Complications 1. Diabetic Retinopathy 2. Diabetic Nephropathy 3. Diabetic Neuropathy 4. Coronary Artery Disease Sports MedicineMario Cesar Moreira de Araujo, MD & Marcelo Riccio Facio, MDDiabetes Mellitus and ExerciseIntroductionNowadays the development of convinient and efficient ways of self monitoring bloodglucose, ande the admission of benefits of regular exercing permit and enconrage morediabetics to engage into exercise programs. Consequenty, phisicians will have to be ableto prescribe arrangements in calorie ingestion and insulin dosage, as well imaginepossible hypoglycemia and unexpected prolonged exercise to permit a safe participationon this activities.Diabets Mellitus is a chronic discase characterized by relative or absolute absence ofinsulin, with repercussion on glucose metabolism classified in Type I (Insulin DependentDiabetes), Type II (Non - Insulin Dependent Diabetes), Secondary Diabetes and GeneticDefects of the Insulin Receptor. Diabetes Mellitus is a very common disoider, with anestimated prevalence between 2 and 4 % in the Unitede States.
Type I Insulin - Dependent Diabetes Mellitus (IDDM) is better characterized by an auto-imune disturbance in which panereatic b cells are distructed. Because off the markedhupoinsulinemia patients usually presents hyperglycemia (with acute complications:polymia, polydipsia and polyfagia) and the risk of developing ketoacidosis.This chapter entends help the medical student to “get contact” with clinical control ofIDDM and NIDDM patients and is diveded in four basical parts: (1) Normal MetabolismDuring Exercise (2) Utilization of glucose on diabetics that exercise themselves (3)Beneficts and risks of exercises for diabetics (4) Terapeutic estrategis.Glucose Metabolism During ExerciseDuring exercise, muscle utilises metabolic fuels at an increased rate to provide the inergyrequired for contraction. In healthy individual, muscle glycogen is the predominant fuelused during very stenuous, short term exercise, whereas blood-borne glucose and freefatty acids (FFA) derived from adipose tissue triglycerides are used preferentially duringprolonged exercise of low to moderate intensity. Glucose uptake by muscle increases 4 -to 5 - fold or more during exercises. Despite this, the level of glucose in the plasma ismaintained as a result of enhanced glucose produciton by the liver.At the onset of exercise and before increased oxygen transport by the circulatory system,the anaerobic breakdown of glycogen to form lactate provides an immediate source ofadenosine triphosphate (ATP). Exercise that continues more than 30 minutes increasesthe dependence on blood borne energy sources. After 60 a 90 minutes of exercise, FFAare the principal energy source. The utilization of FFA continues to discrease as theduration of exercises increases. The “ability” to use glucose and to a greater extent FFAas an energy source is greatly influenced by endurance training. Trained subjects use ahigher proportion of FFA than untramed subjects and are able to spare glycogen storeswhile minimizing lactate production: Occasionally singnificant hyperglycemia andclinically important hypoglycemia occur in normal individuals. Plasma glucose, nowever,remains within a narrow range when exercising at moderate intensities (30% a 60%) CO2max.Energy utilization at exercise is influenced by insulin and by counterregulatoryhormones: glucagon, epinephrine and norepinephrine, cortisol, and growth hormone. Therole of insulin in glucose transport to muscle is markedly reduce during exercise. Themost significant effect of insulin during exercise involves inhibition of hepaticglycogenolysis / gluconeogenesis and lipolysis. Insulin secretion is also suppressed by thealpha-adrenergic inhibition of the pancreatic beta cell, allowing for mobilization ofhepatic glucose and avoidance of hypoglycemia. Exercise also increases insulinsensitivity by enhancing the binding of insulin to receptor sites on the muscle cell. Thisallows for increased glucose uptake without changes in insulin concentration. Increasednumbers of receptor sites area found in more fit individuals with increased insulin bidingand insulin sensitivity lasting for up to 24 hours after exercise.
Greater use of hepatic glucose occurs to prevent hypoglicemia as glucose is used byexercising muscles. This increase in glucose production occurs throught hepaticglycogenolysis. Subsequently gliconeogenesis becomes increasingly important and isinfluenced by counterregulatory hormones.In addition, adrenaline may act to maintain normoglycemia increasing muscleglicogenolysis adiposea tissue lipolysis, there by diminishing the need of blood bornglucose.Exercise in Type I Diabetes MellitusChanges in glucose homeostasis in the type I diabetic are variable and depend on thefollowing factors: degree of insulin administration, prior metabolic control, the presenceor absence of autonomic neuropathy, and caloric intake. Balanced energy supply andinsulin availability can have significant effects on the exercising athlete with type Idiabetes. Excessive insulin levels suppress hepatic glucose production, and lowred serumglucose levels may be met by deficient glucagon secretion, which is common afterseveral years of disease.The well-controlled diabetic may commonly work out for approximately 30 to 45minutes of sustained intense aerobic exercise without problems. Type I patients may havedecreased glycogen stores in the liver and to a lesser extent in skeletal muscle. Lack ofadequate glycogen stores leads to impaired aerobic exercise endurance when comparedwith normals.Hypoglycemia is a common ocurrence in type I diabetics while exercising. In normalsubjects, plasma insulin levels decrease during exercise. Additionally, insulincounterrulatory hormones (glucagon an epinephrine) promote increased hepatic glucoseproduction, which matches the amount of glucose used during exercise. In the type Idiabetic, plasma insulin concentrations may not fall during exercise and may evenincrease if exercise occurs within 1 hour of insulin injection. These sustained insulinlevels during exercise enhance peripheral glucose uptake and stimulate glucose oxidationby exercising muscle. More important, however, is tye inhibition of hepatic glucoseproduction. Hight insulin levels inhibit both gluconeogenesis and glycolenolysis. Eventhought adrenergic stimulation leads to excess production of counterregulatory hormones,hepatic glucose production fails to match the rate of peripheral utilization. Duringexercise of moderate duration, these effects may be considered beneficial; however,longe periods of exercise may result in hypoglycemia.The type I diabetic is at greatest risk of developing severe hypoglycemia 6 to 14 hoursafter strenuous exercise. Muscle and hepatic glycogen must be restored during periods ofrest. Combined wity increased insulin sensitivity in the postexercise period, depletedmuscle glycogen stores along wity tye activation of glycogen synthetase in musclecontribute significantly to tye risk of hypoglycemia. Insulin and caloric intake must beadjusted after strenuous exercise to avoid severe nocturnal hypoglycemia. Hypoglycemiadue to increased insulin absorption from injection sites of actively exercising extremities
as been described. Consequently the abdomen has been recommended as the abdomenhas been recommended as the primary injection site in the exercising diabetic.Absorption of insulin from the abdomen is generally faster and more reliable than usinglimb sities for injection and consequently does not prevent the occurrence ofhypoglycemia.Finally, the type I diabetic does not increase insulin secretion postexercise.Hyperglycemia after exertion can be profound and prolonged for days owing to insulindeficiency. In the presence of poor control and ketonuria, further exercise can lead toimpaired glucose uptake and increased lipolysis, ketogenesis, and hepatic glucoseproduction. The patient may rapidly unless exogenous insulin is given to the patient.Exercise in Type II Diabetes MellitusInitial treatment of type II diabetes consists of weight reduction, dietary control, exercise,and oral hypoglycemic agents. Insulin replacement is seldom necessary but should beadded to the treatment regimen when hyperglycemia remains unchecked by thesemethods. Exercise is a major contributor in controlling hyperglycemia through improvedperipheral insulin sensitivity, enhanced insulin binding, and reduced obesity.Exercise can aid glycemic control and in combination with proper diet help prevent typeII diabetes from occurring in those persons at risk. Exercise does this by improving short-term insulin sensitivity and reducing insulin resistance, both of which begin to disappeara few days after exercise is discontinued. Althought the number of insulin receptorsremains constant with exercise, the biding of insulin to adipocytes is increased with noincrease noted in binding to myocytes. In both cell types, however, the number andactivity of glucose transport proteins (particularly Glut-4-isoform) are increased withexercise. This results in an increase in insulin-stimulated glucose transport into these cellsfollowing exercise, which improves glycemic control.With the onset of exercise, the type II patient, does not respont with a decrease in serumglucose concentration as in the nondiabetic. This is due to increased glucose uptake in theperipheral tissues. As a result, serum glucose is higher, and liver glucose production ishalted to allow for normalization of the hyperglycemia by overall reduction in theglucose level. In constrast to the type I patient, type II diabetics do not usually sufferhypoglycemia because endogenous insulin levels can usually be maintained. Thoseathletes on oral hypoglycemic agents or insulin, however, may have problems withglucose homeostasis during exercise. The athlete may need to lower the medication doseor increase carbohydrate intake (or both) before exercise to prevent hypoglycemia.Severe hypoglycemia is unusual because individuals are still able to reduce endogenousinsulin production as blood glucose levels decline.Bibliography1. Sports Medicine for Primary Care, Willian E. Moats2. Goodman, The Pharmacological Basis of Therapheutics, Nineth Edition, Goodman &
Gilman’s3. The Medical Clinics of North America, Vol 78, Num 2 , Gray I. Wadler.4. Cecil , Textbook of Medicine. twenth edition, Bennet & Plum5. Exercise prescription fo Individuals with metabolic disorders (pratical considerations)John C. Young. SPORTS MED. 19(1) PAG 43 - 54 1995Selected Guidelines: Diabetes Mellitus and Exercise • • Definition and Description of Diabetes Mellitus • Classification of Diabetes Mellitus and Other Categories of Glucose Regulation • Diagnostic Criteria for Diabetes Mellitus • Position Statements • Implications of the Diabetes Control and Complications Trial (DCCT) • Standards of Medical Care for Patients With Diabetes Mellitus • Nutrition Recommendations and Principles for People With Diabetes Mellitus - Medical Nutrition Therapy (MNT) • Diabetes Mellitus and Exercise • Preventive Foot Care in People With Diabetes • Management of Dyslipidemia in Adults With Diabetes • Aspirin Therapy in Diabetes • Smoking and Diabetes • Pre-Conception Care of Women With Diabetes • Diabetic Nephropathy • Diabetic Retinopathy • Gestational Diabetes Mellitus • Tests Of Glycemia in Diabetes • Hyperglycemic Crises in Patients With Diabetes Mellitus • Pancreas Transplantation for Patients With Type 1 Diabetes • Pre-Conception Care of Women With Diabetes • Continuous Subcutaneous Insulin Infusion (CSII) • Immunization and the Prevention of Influenza and Pneumococcal Disease in People With Diabetes • Food Labeling • Role of Fat Replacers in Diabetes Medical Nutrition Therapy • Care of Children With Diabetes in the School and Day Care Setting
Diabetes Mellitus and ExercisePhysical activity is paramount in health promotion and disease prevention. A directcorrelation exists between the epidemic proportion of patients with type 2 diabetes, thedecreasing levels of activity, and increasing prevalence of obesity.Evaluation of the Patient Before ExerciseA detailed medical evaluation including medical history, physical examination,diagnostic studies, and screening for macrovascular and microvascular complications andsigns of disease affecting the heart and blood vessels, eyes, kidneys, and nervous systemshould be completed. • Cardiovascular system: A graded exercise test or radionuclide stress test is recommended for patients at high risk for underlying cardiovascular disease based on one of the following criteria: age >35 years, type 2 diabetes of >10 years duration or type 1 diabetes of >15 years duration, presence of any other risk factor for coronary artery disease, or presence of microvascular disease, peripheral vascular disease, or autonomic neuropathy. • Peripheral arterial disease: In the evaluation of peripheral arterial disease (PAD), a dorsalis pedis and posterior tibial pulse does not rule out ischemic changes in the forefoot. • Retinopathy: The degree of retinopathy determines the risk associated with exercise; hence an individualized exercise regimen is needed. • Nephropathy: No recommendations exist for patients with incipient or overt nephropathy, although patients with overt nephropathy are often limited in activity level due to a reduced capacity for exercise. • Peripheral neuropathy (PN): Weight bearing and repetitive exercises should be limited in patients with significant PN, as they may cause ulceration and fractures. Exercises that are contraindicated include treadmill use, prolonged walking, jogging, and step exercises. Recommended exercises include swimming, bicycling, rowing, chair exercises, arm exercises, and other non-weight-bearing exercises. Evaluation of PN includes checking the deep tendon reflexes, vibratory sense, position sense and touch sense. • Autonomic neuropathy: Patients with autonomic neuropathy have a reduced exercise capacity and are at increased risk for an adverse cardiovascular event while exercising. Manifestations of cardiac autonomic neuropathy (CAN) include a resting tachycardia of >100 beats per minute, orthostasis, or other disturbances in autonomic nervous system function involving the skin, pupils, gastrointestinal, or genitourinary systems.
Preparing for ExerciseAll exercise regimens should begin with a warm-up period and end with a cool-downperiod.Trauma to the feet should be minimized, especially for individuals with PN, by wearingproper footwear and using silica gel or air midsoles to prevent blisters and to keep thefeet dry.Plenty of fluids should be taken prior to and during exercise, taking special precautionswhen exercising in extremely hot or cold environments.For young individuals with diabetes, high-resistance exercise with weights or moderateweight training programs are acceptable.For older individuals with diabetes, only moderate weight training using light weightswith high repetitions can be used.Exercise and Type 2 DiabetesLong-term exercise programs have a beneficial effect on carbohydrate metabolism andinsulin sensitivity, have been effective in reducing triglyceride-rich VLDL and bloodpressure levels, and may enhance weight loss.An association exits between aerobic fitness and fibrinolysis.Exercise may be helpful in preventing or delaying the onset of type 2 diabetes.Exercise and Type 1 DiabetesHypoglycemia can occur at any time before, during, or after exercising but can beavoided by following some general guidelines: • Avoiding exercise if fasting glucose levels are >250 mg/dL and ketosis is present, and use caution if glucose levels are >300 mg/dL and no ketosis is present prior to exercise. • Consuming additional carbohydrates if glucose levels are <100 mg/dL prior to exercise. • Monitoring blood glucose before and after exercise to identify when changes in insulin or food intake are necessary and to learn how the glycemic response differs among various exercises. • Adjusting the regimen to allow safe participation in all forms of physical activity consistent with the individuals desires and goals. • To avoid hypoglycemia, have carbohydrate foods available during and after exercise.
Exercise in the ElderlyA decrease in fitness is preventable through regular exercise.A decrease in physical activity in part causes a decrease in insulin sensitivity with aging. **********************