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Exercise in DiabetesExercise in Diabetes
Exercise in
Diabetes Mellitus
Dr Shahjada SelimDr Shahjada Selim
Department of EndocrinologyDepartment of Endocrinology
Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical University
EmailEmail::selimshahjada@gmail.comselimshahjada@gmail.com
January 1, 2016January 1, 2016 11
DefinitionsDefinitions
 Any bodily movement produced by the
skeletal muscles resulting in energy
expenditure above resting state.
Exercise in DiabetesExercise in Diabetes
Physical Activity
Caspersen, et al., Public health Rep,1985
11
January 1, 2016January 1, 2016 22
DefinitionsDefinitions
Exercise in DiabetesExercise in Diabetes
A set of attributes that people have or
achieve, which relates to the ability to
perform physical activity.
Caspersen, et al., Public health Rep,1985
11
January 1, 2016January 1, 2016 33
Physical Fitness
DefinitionsDefinitions
 The amount of energy expended during
exercise relative to the energy expenditure
during rest.
Exercise in DiabetesExercise in Diabetes
Metabolic Equivalent (MET)
Energy expenditure during rest = 1 MET
= 3.5 ml of O2 / kg. min
= 1 kcal / kg. hr
22
January 1, 2016January 1, 2016 44
DIABETES MANAGEMENT “TRIAD”DIABETES MANAGEMENT “TRIAD”
Medication
Nutrition
EXERCIS
E
Classification of Exercise
Aerobic exercise:
Endurance type exercise, rhythmic,
sustained for sometimes.
Example:
Walking, jogging, running, cycling,
swimming, etc…
Exercise in DiabetesExercise in Diabetes
January 1, 2016January 1, 2016
66
Classification of ExerciseClassification of Exercise
Exercise in DiabetesExercise in Diabetes
Strength (Resistance) exercise:
Weight training with free weight,
machine, elastic rope, calisthenics, etc…
Flexibility exercise:
Stretching exercise.
January 1, 2016January 1, 2016
77
Physical Activity Intensity in MET
Light: Less than 3 MET
Exercise in DiabetesExercise in Diabetes
Moderate: 3 – 6 MET
Vigorous: Above 6 MET
CDC, 1996 January 1, 2016January 1, 2016
88
Moderate & Vigorous IntensityModerate & Vigorous Intensity
Physical ActivitiesPhysical Activities
Exercise in DiabetesExercise in Diabetes
Moderate:
Brisk walking, Recreational swimming,
Volleyball, Slow aerobics, Moderate cycling
Gardening, Tennis-double, Badminton etc..
Vigorous:
Jogging, Running, Tennis-single, Basketball,
Rope skipping, Squash, Fast aerobics, Fast
cycling, Stepping, Soccer, etc
January 1, 2016January 1, 2016
99
Exercise in DiabetesExercise in Diabetes
What is the Amount of Physical ActivityWhat is the Amount of Physical Activity
that Promotes Health?that Promotes Health?
 Moderate Intensity Physical Activity.
 Energy Expenditure = 3 - 6 MET
 That is: ≥ 30 min/day, ≥ 5 days/week.
 150 min. per week.
ACSM, 2000; CDC, 1996
 ≥ 1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000
January 1, 2016January 1, 2016 1010
Exercise in DiabetesExercise in Diabetes
ExerciseExercise &&
DiabetesDiabetes
January 1, 2016January 1, 2016 1111
Exercise in DiabetesExercise in Diabetes
Can Exercise PreventCan Exercise Prevent
oror Delay DiabetesDelay Diabetes ??
Evidences fromEvidences from
Randomized Clinical TrialsRandomized Clinical Trials
January 1, 2016January 1, 2016 1212
Malmo
Study
Sweden 260males
(6 yrs)
Eriksson & Lindgarde,Eriksson & Lindgarde,
Diabetologia,Diabetologia, 1999119991
Da Qing, China China 577males &
Females (6 yrs)
Pan, et al,Pan, et al,
Diabetes Care,Diabetes Care, 19971997
The Nurse’s
Health Study
USA 70,000
Nurses (8 yrs)
Hu, et alHu, et al.,.,
JAMA,JAMA, 19991999
Finnish
Experimental
Study
Finland 523males&
Females (4 yrs)
Tuomilehto, et al.,Tuomilehto, et al., NN
Engl J Med,Engl J Med, 20012001
Diabetes
Prevention Study
USA 3234males &
Females (3 yrs)
Diabetes Prev. ProgramDiabetes Prev. Program
Research GroupResearch Group,,
N Engl J Med,N Engl J Med, 20022002
Exercise inExercise in
DiabetesDiabetes
Exercise in the Prevention of DiabetesExercise in the Prevention of Diabetes
Participants are either normal or haveParticipants are either normal or have ++ GTTGTT
Exercise in DiabetesExercise in Diabetes January 1, 2016January 1, 2016 1414
Exercise in DiabetesExercise in Diabetes
Moderate Physical ActivityModerate Physical Activity
Performed Regularly for 120 – 200Performed Regularly for 120 – 200
min. per week reduces themin. per week reduces the
Incidence of diabetes in PeopleIncidence of diabetes in People
Predisposed to DiabetesPredisposed to Diabetes..
Exercise in the Prevention of diabetesExercise in the Prevention of diabetes
Summary of the ResultsSummary of the Results
January 1, 2016January 1, 2016 1515
Exercise in DiabetesExercise in Diabetes
ExerciseExercise in thein the
Management ofManagement of
DiabetesDiabetes
January 1, 2016January 1, 2016 1616
Exercise in DiabetesExercise in Diabetes
Exercise & Type 1 DiabetesExercise & Type 1 Diabetes
Improves physical fitness.Improves physical fitness.
Increases self confidence.Increases self confidence.
Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.
It has no direct effect on glucose control.It has no direct effect on glucose control.
Proper timing of Exercise & Insulin.Proper timing of Exercise & Insulin.
Avoid strenuous exercise before bed time.Avoid strenuous exercise before bed time.
January 1, 2016January 1, 2016 1717
Exercise in DiabetesExercise in Diabetes
Exercise & Type 2 DiabetesExercise & Type 2 Diabetes
Improves physical fitness & reduces fat %.Improves physical fitness & reduces fat %.
Increases self confidence.Increases self confidence.
Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.
Improves glucose control:Improves glucose control:
 Improving insulin sensitivity.Improving insulin sensitivity.
 Increasing Glu T4Increasing Glu T4 (glucose transporters).(glucose transporters).
January 1, 2016January 1, 2016 1818
0
5
10
15
20
0 30 60 90 120 150 180
Before After
Exercise inExercise in
DiabetesDiabetes
Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 DiabeticsPlasmaGlucosePlasmaGlucose(mmol/l)(mmol/l)
TimeTime (min)(min)
12 months of Training12 months of Training
Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
0
400
800
1200
1600
0 30 60 90 120 150 180
Before After
Exercise inExercise in
DiabetesDiabetes
Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 Diabetics
PlasmaInsulinPlasmaInsulin(pmol/l)(pmol/l)
TimeTime (min)(min)
12 months of Training12 months of Training
Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
Exercise in DiabetesExercise in Diabetes
Exercise
Prescription
for Diabetic
January 1, 2016January 1, 2016 2121
Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 1/41/4
Aerobic activity for 30Aerobic activity for 30 min.min. extendedextended (gradually)(gradually)
to 60to 60 min.min. every day or most days/week/ 150every day or most days/week/ 150
mins per wk.mins per wk.
HR during activity should be graduallyHR during activity should be gradually
increased to reach 60 – 70% of HR max.increased to reach 60 – 70% of HR max.
Exercise session should include 5-10 min. ofExercise session should include 5-10 min. of
warm-up and a 5 min of cool-down.warm-up and a 5 min of cool-down.
Exercise must involve most major muscles inExercise must involve most major muscles in
both lower and upper parts of the body.both lower and upper parts of the body.
January 1, 2016January 1, 2016 2222
Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 2/42/4
Moderate intensity weight training programModerate intensity weight training program
is recommended to maintain muscle strengthis recommended to maintain muscle strength
( 8-12 repetitions 2 times /week).( 8-12 repetitions 2 times /week).
Exercise must be regular. Benefits areExercise must be regular. Benefits are
diminished after 1 -2 weeks of stopping .diminished after 1 -2 weeks of stopping .
For those with feet problems, avoid running.For those with feet problems, avoid running.
Alternate between walking, swimming, and cycling.Alternate between walking, swimming, and cycling.
January 1, 2016January 1, 2016 2323
Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 3/43/4
When using insulin, avoid exercise if glucoseWhen using insulin, avoid exercise if glucose
levels below 100 mg/dl or above 250 mg/dl.levels below 100 mg/dl or above 250 mg/dl.
Use proper shoes, with silica gel or air-filledUse proper shoes, with silica gel or air-filled
soles, and always keep feet dry.soles, and always keep feet dry.
Avoid dehydration by keeping your bodyAvoid dehydration by keeping your body
always hydratedalways hydrated..
Do not inject insulin into a body part that isDo not inject insulin into a body part that is
expected to be used during exercise.expected to be used during exercise.
January 1, 2016January 1, 2016 2424
Exercise in DiabetesExercise in Diabetes
Graded Exercise Testing for DiabeticGraded Exercise Testing for Diabetic 4/44/4
It is recommended before any moderate toIt is recommended before any moderate to
high intensity exercise, especially if:high intensity exercise, especially if:
 Age is > 35 yrs.Age is > 35 yrs.
 Type 2 diabetes for > 10 yrs duration.Type 2 diabetes for > 10 yrs duration.
 Type 1 diabetes for > 15 yrs duration.Type 1 diabetes for > 15 yrs duration.
 Presence of any CHD risk factors.Presence of any CHD risk factors.
 Presence of microvascular diseasePresence of microvascular disease
(retinopathy, nephropathy).(retinopathy, nephropathy).
 Presence of peripheral vascular disease.Presence of peripheral vascular disease.
ADA Position Statement, Diabetes Care, 2002ADA Position Statement, Diabetes Care, 2002
January 1, 2016January 1, 2016 2525
Exercise in DiabetesExercise in Diabetes
ExerciseExercise
Prescription forPrescription for
Special CasesSpecial Cases
January 1, 2016January 1, 2016 2626
Exercise in DiabetesExercise in Diabetes
Diabetic withDiabetic with Peripheral NeuropathyPeripheral Neuropathy
Repetitive exercise on insensitive feet canRepetitive exercise on insensitive feet can
lead to ulceration & fractureslead to ulceration & fractures..
Peripheral neuropathy may results in lossPeripheral neuropathy may results in loss
of sensation in the feet.of sensation in the feet.
Limit weight-bearing exerciseLimit weight-bearing exercise (Treadmill,(Treadmill,
Prolonged walking, Jogging, Step exercise, etc..)Prolonged walking, Jogging, Step exercise, etc..)
Use proper shoes, and always monitor the feetUse proper shoes, and always monitor the feet..
Alternative exercises areAlternative exercises are: Swimming,: Swimming,
Bicycling, Arm exercise, Chair exercise, etc..Bicycling, Arm exercise, Chair exercise, etc..
January 1, 2016January 1, 2016 2727
Exercise in DiabetesExercise in Diabetes
Diabetic withDiabetic with Autonomic NeuropathyAutonomic Neuropathy
Hypotension and hypertension are moreHypotension and hypertension are more
likely to develop after vigorous exercise.likely to develop after vigorous exercise.
This condition may limit exercise capacity &This condition may limit exercise capacity &
increase the risk of CV event during exercise.increase the risk of CV event during exercise.
Those patients may have difficulty withThose patients may have difficulty with
thermoregulation:thermoregulation:
 Avoid exercise in hot or cold environments.Avoid exercise in hot or cold environments.
 encourage adequate hydration.encourage adequate hydration.
January 1, 2016January 1, 2016 2828
Hypoglycemia during or after ExerciseHypoglycemia during or after Exercise
 It will most likely occur if the patient:
 Takes insulin or diabetes pill.
 Skips a meal.
 Exercises for a long time.
 Exercises strenuously.
Exercise in DiabetesExercise in Diabetes
If it occurs, what can be done?
 Patient must eat a snack before exercise, or.
 Adjusts the medication dose.
 Remember: Patient should always carry a source
of CHO with him ( An apple or orange juice, or a piece of
fruit).
January 1, 2016January 1, 2016 2929
Exercise in DiabetesExercise in Diabetes
Energy ExpenditureEnergy Expenditure
duringduring
Physical Activity!Physical Activity!
January 1, 2016January 1, 2016 3030
ActivityActivity CaloreiCalorei
Brisk walkingBrisk walking 0.070.07
RunningRunning (7.5 min per km)(7.5 min per km) 0.130.13
RunningRunning (5 min per km)(5 min per km) 0.2080.208
SwimmingSwimming 0.1620.162
Rope skippingRope skipping (70/min)(70/min) 0.1620.162
Rope skippingRope skipping (80/min)(80/min) 0.1650.165
BadmintonBadminton 0.0970.097
TennisTennis 0.1090.109
SquashSquash 0.2120.212
BasketballBasketball 0.1380.138
Energy Cost of Physical ActivityEnergy Cost of Physical Activity
((kilocalorie/kg. minkilocalorie/kg. min))
McArdle, et., 1991
January 1, 2016 Exercise in Diabetes 31
ActivityActivity METMET
WalkingWalking (slow)(slow) 2.52.5
Walking (Walking (Brisk)Brisk) 44
RunningRunning (7.5 min per km)(7.5 min per km) 88
SwimmingSwimming 66
Rope skippingRope skipping (slow)(slow) 88
Weight trainingWeight training 66
BadmintonBadminton 4.54.5
TennisTennis (single)(single) 88
SquashSquash 1212
BasketballBasketball 88
Energy Cost of Physical ActivityEnergy Cost of Physical Activity
((METMET))
Ainsworth, et., 2000
January 1, 2016 Exercise in Diabetes 32
Exercise in DiabetesExercise in Diabetes
How to CalculateHow to Calculate
Energy ExpenditureEnergy Expenditure
during Brisk Walkingduring Brisk Walking!!
January 1, 2016January 1, 2016 3333
Exercise in DiabetesExercise in Diabetes
== 0.070.07 k.k. caloriecalorie per kg of body weightper kg of body weight //
min.min.
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
An Example:An Example:
aa person weighing 76 kg would expend:person weighing 76 kg would expend:
0.070.07 X 76 =X 76 = 5.35.3 k.k. calorie per min.calorie per min.
January 1, 2016January 1, 2016 3434
Exercise in DiabetesExercise in Diabetes
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
 If he has to expend 1200 k.If he has to expend 1200 k. calories per week.calories per week.
How much time he should walk per week?How much time he should walk per week?
 1200 / 5.3 = 226.4 min.1200 / 5.3 = 226.4 min.
= 45 min / 5 days per week, or= 45 min / 5 days per week, or
= 57 min / 4 days per week.= 57 min / 4 days per week.
January 1, 2016January 1, 2016
3535
Preparing For Exercise
 Proper warm-up
consisting of 5–10 min of
aerobic activity
 Activity session 15- 30
mins
 cool-down should be
structured similarly to
the warm-up and
should last about 5–10
min
Types of Physical Activity
The Mnemonic: “SAFE” exercises are
recommended:
 Strengthening exercises
 Aerobic exercises
 Flexibility exercises
 Endurance exercises
Aerobic exercise
 With Oxygen
 Aerobic exercise is the type
that moves large muscle
groups and causes you to
breathe more deeply and
your heart to work harder to
pump blood. It's also called
cardiovascular exercise. It
improves the health of your
heart and lungs.
Anaerobic (Resistance) Exercise
 Anaerobic exercise
uses large muscles
that do not require
oxygen for short
periods of exercise. It
helps build strong
muscles; lowers blood
glucose makes the
action of insulin more
effective.
Flexibility (Stretching) Exercise
 Flexibility exercises are
aimed at increasing or
maintaining range of
motion at joints, also
improve tone in muscles
and keep it supple.
They develop better
muscular and body
control.
Endurance Exercises
 Low Resistance, High
Repetition Exercises
 Examples:
Walking, cycling,
swimming, or upper
extremity ergometry
that involve the use of
the large muscle of the
body.
How much exercise?
Exercises should be done according to FITT principle.
 FREQUENCY: Exercising 4 to 6 times a week.
 INTENSITY: 30-40 min of exercise at 50- 60 % of target
heart rate.
 TYPE: SAFE exercises are recommended.
 TIME: Morning is ideal
A SAMPLE WALKING PROGRAM
Warm Up Target Zone Exercising Cool Down Time Total
Week 1
Session A Walk normally 5 min. Then walk briskly 5 min. Then walk normally 5 min. 15 min.
Session B --Repeat above pattern--
Session C --Repeat above pattern--
Continue with at least three exercise sessions during each week of the program. If you find a particular week's pattern tiring, repeat it before going on to the next pattern. You
do not have to complete the walking program in 12 weeks.
Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min.
Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min.
Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min.
Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min.
Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min.
Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min.
Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min.
Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min.
Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min.
Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min.
Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min.
Week 13 and thereafter:
Check your pulse periodically to see if you are exercising within your target zone. As you get more in
shape, try exercising within the upper range of your target zone. Gradually increase your brisk
walking time to 30 to 60 minutes, three or four times a week.
Breathing Exercises
Neck Exercises
Hand Exercises
Trunk Exercises
Trunk Exercises…………
Leg Exercises
Peripheral and autonomic neuropathy
Recommended
non-weight-
bearing activities
swimming
bicycling
chair and arm
exercises
Contraindicated
treadmill
prolonged
walking
jogging
step exercises
Nephropathy
Recommended
Low to
moderate
intensity forms of
exercise
Contraindicated
High intensity
forms of
exercise
Diabetic retinopathy
Recommended
 Low-impact
cardiovascular
conditioning, such
as swimming,
walking, low-impact
aerobics, stationary
cycling, endurance
exercises
Contraindicated
 Strenuous activities,
pounding or jarring,
such as weight lifting,
jogging, high-impact
aerobics, racquet
sports.
Hypoglycemia Management
The person should be instructed to stop
exercising. People at risk for hypoglycemia
should always carry a source of glucose with
them such as glucose tablets, candy or juice in
order to treat hypoglycemia.
Remember- it is a medical emergency
Snacking to prevent hypoglycemia
Basic Rules:
 Snack prior to activity to prevent hypoglycemia
 Adjust quantity based on pre-activity BG or direction of BG
 BG low or dropping:  usual carbs
 BG OK or stable: usual carbs
 BG High or rising:  usual carbs
 Snack at least once per hour during prolonged activity
 Choose high-glycemic forms of carbohydrate
Source: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
Useful Tips For Exercise
 Always carry an
identification card with you
 Check your feet before you
walk
 Choose good footwear,
light clothing
 Drink lots of water
 Don’t exercise during hot
seasons, and when not
feeling well
What Can Physical Activity Do
For You?
Give you
more energy
What Can Physical Activity Do
For You?
Help you lose
weight and
keep it off
What Can Physical Activity Do
For You?
Increase
flexibility and
strength
Slow bone loss
Provide better
quality of life
What Can Physical Activity Do
For You?
Build muscle
What Can Physical Activity Do
For You?
Improve your
sex life
What Can Physical Activity Do
For You?
Lift your
mood
Treat
depression
What Can Physical Activity Do
For You?
Reduce stress
and anxiety
What Can Physical Activity Do
For You?
Improve
blood
glucose
control
(lowers A1C)
Physical activity lowers blood
glucose in type 2 diabetes by
helping:
 muscle cells become more sensitive to insulin
 keep the liver from producing too much glucose
 build more muscle
 you lose weight and keep it off
What Can Physical Activity Do
For You?
Keep your
heart healthy
Physical activity helps your heart
by:
 Strengthening heart muscle
 Lowering resting heart rate
 Lowering blood pressure
 Improving cholesterol
 Reducing risk of heart attack and stroke
“Sitting” through life increases
your risk of:
 heart disease
 high blood pressure
 high cholesterol
 overweight
 type 2 diabetes
We now must plan physical
activity into our schedule
Getting Started
 Check with your doctor if you:
 Are over age 35
 Have had diabetes more than 10
years
 Have high blood pressure, heart
disease, poor circulation, or other
diabetes complications
Aerobic Activity
 Walking briskly
 Dancing
 Bicycling
 Hiking
 Jogging/running
 Skating
 Stair climbing
 Swimming
 Water exercise
Resistance Activities
 “Push, Pull, and Lift” Activities
 increase muscle strength
 prevent falls
 increase mobility
 improve blood glucose control
Stretching
 Improves your balance and
coordination
 Makes you more flexible
 Reduces stiffness
 Reduces your risk of injury
How Can You Begin?
 Choose activity (example: brisk walking)
 Set a long-term goal - at least 30
minutes a day, 3-5 days a week
 Buy comfortable walking shoes
 Get a partner
Physical Activity Is Like
Magic for Type 2 Diabetes
Exercise in DiabetesExercise in Diabetes January 1, 2016January 1, 2016 7575

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Exercise for Diabetes by Selim

  • 1. Exercise in DiabetesExercise in Diabetes Exercise in Diabetes Mellitus Dr Shahjada SelimDr Shahjada Selim Department of EndocrinologyDepartment of Endocrinology Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical University EmailEmail::selimshahjada@gmail.comselimshahjada@gmail.com January 1, 2016January 1, 2016 11
  • 2. DefinitionsDefinitions  Any bodily movement produced by the skeletal muscles resulting in energy expenditure above resting state. Exercise in DiabetesExercise in Diabetes Physical Activity Caspersen, et al., Public health Rep,1985 11 January 1, 2016January 1, 2016 22
  • 3. DefinitionsDefinitions Exercise in DiabetesExercise in Diabetes A set of attributes that people have or achieve, which relates to the ability to perform physical activity. Caspersen, et al., Public health Rep,1985 11 January 1, 2016January 1, 2016 33 Physical Fitness
  • 4. DefinitionsDefinitions  The amount of energy expended during exercise relative to the energy expenditure during rest. Exercise in DiabetesExercise in Diabetes Metabolic Equivalent (MET) Energy expenditure during rest = 1 MET = 3.5 ml of O2 / kg. min = 1 kcal / kg. hr 22 January 1, 2016January 1, 2016 44
  • 5. DIABETES MANAGEMENT “TRIAD”DIABETES MANAGEMENT “TRIAD” Medication Nutrition EXERCIS E
  • 6. Classification of Exercise Aerobic exercise: Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc… Exercise in DiabetesExercise in Diabetes January 1, 2016January 1, 2016 66
  • 7. Classification of ExerciseClassification of Exercise Exercise in DiabetesExercise in Diabetes Strength (Resistance) exercise: Weight training with free weight, machine, elastic rope, calisthenics, etc… Flexibility exercise: Stretching exercise. January 1, 2016January 1, 2016 77
  • 8. Physical Activity Intensity in MET Light: Less than 3 MET Exercise in DiabetesExercise in Diabetes Moderate: 3 – 6 MET Vigorous: Above 6 MET CDC, 1996 January 1, 2016January 1, 2016 88
  • 9. Moderate & Vigorous IntensityModerate & Vigorous Intensity Physical ActivitiesPhysical Activities Exercise in DiabetesExercise in Diabetes Moderate: Brisk walking, Recreational swimming, Volleyball, Slow aerobics, Moderate cycling Gardening, Tennis-double, Badminton etc.. Vigorous: Jogging, Running, Tennis-single, Basketball, Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Soccer, etc January 1, 2016January 1, 2016 99
  • 10. Exercise in DiabetesExercise in Diabetes What is the Amount of Physical ActivityWhat is the Amount of Physical Activity that Promotes Health?that Promotes Health?  Moderate Intensity Physical Activity.  Energy Expenditure = 3 - 6 MET  That is: ≥ 30 min/day, ≥ 5 days/week.  150 min. per week. ACSM, 2000; CDC, 1996  ≥ 1000 k. calories/week. Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000 January 1, 2016January 1, 2016 1010
  • 11. Exercise in DiabetesExercise in Diabetes ExerciseExercise && DiabetesDiabetes January 1, 2016January 1, 2016 1111
  • 12. Exercise in DiabetesExercise in Diabetes Can Exercise PreventCan Exercise Prevent oror Delay DiabetesDelay Diabetes ?? Evidences fromEvidences from Randomized Clinical TrialsRandomized Clinical Trials January 1, 2016January 1, 2016 1212
  • 13. Malmo Study Sweden 260males (6 yrs) Eriksson & Lindgarde,Eriksson & Lindgarde, Diabetologia,Diabetologia, 1999119991 Da Qing, China China 577males & Females (6 yrs) Pan, et al,Pan, et al, Diabetes Care,Diabetes Care, 19971997 The Nurse’s Health Study USA 70,000 Nurses (8 yrs) Hu, et alHu, et al.,., JAMA,JAMA, 19991999 Finnish Experimental Study Finland 523males& Females (4 yrs) Tuomilehto, et al.,Tuomilehto, et al., NN Engl J Med,Engl J Med, 20012001 Diabetes Prevention Study USA 3234males & Females (3 yrs) Diabetes Prev. ProgramDiabetes Prev. Program Research GroupResearch Group,, N Engl J Med,N Engl J Med, 20022002 Exercise inExercise in DiabetesDiabetes Exercise in the Prevention of DiabetesExercise in the Prevention of Diabetes Participants are either normal or haveParticipants are either normal or have ++ GTTGTT
  • 14. Exercise in DiabetesExercise in Diabetes January 1, 2016January 1, 2016 1414
  • 15. Exercise in DiabetesExercise in Diabetes Moderate Physical ActivityModerate Physical Activity Performed Regularly for 120 – 200Performed Regularly for 120 – 200 min. per week reduces themin. per week reduces the Incidence of diabetes in PeopleIncidence of diabetes in People Predisposed to DiabetesPredisposed to Diabetes.. Exercise in the Prevention of diabetesExercise in the Prevention of diabetes Summary of the ResultsSummary of the Results January 1, 2016January 1, 2016 1515
  • 16. Exercise in DiabetesExercise in Diabetes ExerciseExercise in thein the Management ofManagement of DiabetesDiabetes January 1, 2016January 1, 2016 1616
  • 17. Exercise in DiabetesExercise in Diabetes Exercise & Type 1 DiabetesExercise & Type 1 Diabetes Improves physical fitness.Improves physical fitness. Increases self confidence.Increases self confidence. Improves CV function & CHD risk profile.Improves CV function & CHD risk profile. It has no direct effect on glucose control.It has no direct effect on glucose control. Proper timing of Exercise & Insulin.Proper timing of Exercise & Insulin. Avoid strenuous exercise before bed time.Avoid strenuous exercise before bed time. January 1, 2016January 1, 2016 1717
  • 18. Exercise in DiabetesExercise in Diabetes Exercise & Type 2 DiabetesExercise & Type 2 Diabetes Improves physical fitness & reduces fat %.Improves physical fitness & reduces fat %. Increases self confidence.Increases self confidence. Improves CV function & CHD risk profile.Improves CV function & CHD risk profile. Improves glucose control:Improves glucose control:  Improving insulin sensitivity.Improving insulin sensitivity.  Increasing Glu T4Increasing Glu T4 (glucose transporters).(glucose transporters). January 1, 2016January 1, 2016 1818
  • 19. 0 5 10 15 20 0 30 60 90 120 150 180 Before After Exercise inExercise in DiabetesDiabetes Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 DiabeticsPlasmaGlucosePlasmaGlucose(mmol/l)(mmol/l) TimeTime (min)(min) 12 months of Training12 months of Training Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
  • 20. 0 400 800 1200 1600 0 30 60 90 120 150 180 Before After Exercise inExercise in DiabetesDiabetes Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 Diabetics PlasmaInsulinPlasmaInsulin(pmol/l)(pmol/l) TimeTime (min)(min) 12 months of Training12 months of Training Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
  • 21. Exercise in DiabetesExercise in Diabetes Exercise Prescription for Diabetic January 1, 2016January 1, 2016 2121
  • 22. Exercise in DiabetesExercise in Diabetes Exercise Prescription for DiabeticExercise Prescription for Diabetic 1/41/4 Aerobic activity for 30Aerobic activity for 30 min.min. extendedextended (gradually)(gradually) to 60to 60 min.min. every day or most days/week/ 150every day or most days/week/ 150 mins per wk.mins per wk. HR during activity should be graduallyHR during activity should be gradually increased to reach 60 – 70% of HR max.increased to reach 60 – 70% of HR max. Exercise session should include 5-10 min. ofExercise session should include 5-10 min. of warm-up and a 5 min of cool-down.warm-up and a 5 min of cool-down. Exercise must involve most major muscles inExercise must involve most major muscles in both lower and upper parts of the body.both lower and upper parts of the body. January 1, 2016January 1, 2016 2222
  • 23. Exercise in DiabetesExercise in Diabetes Exercise Prescription for DiabeticExercise Prescription for Diabetic 2/42/4 Moderate intensity weight training programModerate intensity weight training program is recommended to maintain muscle strengthis recommended to maintain muscle strength ( 8-12 repetitions 2 times /week).( 8-12 repetitions 2 times /week). Exercise must be regular. Benefits areExercise must be regular. Benefits are diminished after 1 -2 weeks of stopping .diminished after 1 -2 weeks of stopping . For those with feet problems, avoid running.For those with feet problems, avoid running. Alternate between walking, swimming, and cycling.Alternate between walking, swimming, and cycling. January 1, 2016January 1, 2016 2323
  • 24. Exercise in DiabetesExercise in Diabetes Exercise Prescription for DiabeticExercise Prescription for Diabetic 3/43/4 When using insulin, avoid exercise if glucoseWhen using insulin, avoid exercise if glucose levels below 100 mg/dl or above 250 mg/dl.levels below 100 mg/dl or above 250 mg/dl. Use proper shoes, with silica gel or air-filledUse proper shoes, with silica gel or air-filled soles, and always keep feet dry.soles, and always keep feet dry. Avoid dehydration by keeping your bodyAvoid dehydration by keeping your body always hydratedalways hydrated.. Do not inject insulin into a body part that isDo not inject insulin into a body part that is expected to be used during exercise.expected to be used during exercise. January 1, 2016January 1, 2016 2424
  • 25. Exercise in DiabetesExercise in Diabetes Graded Exercise Testing for DiabeticGraded Exercise Testing for Diabetic 4/44/4 It is recommended before any moderate toIt is recommended before any moderate to high intensity exercise, especially if:high intensity exercise, especially if:  Age is > 35 yrs.Age is > 35 yrs.  Type 2 diabetes for > 10 yrs duration.Type 2 diabetes for > 10 yrs duration.  Type 1 diabetes for > 15 yrs duration.Type 1 diabetes for > 15 yrs duration.  Presence of any CHD risk factors.Presence of any CHD risk factors.  Presence of microvascular diseasePresence of microvascular disease (retinopathy, nephropathy).(retinopathy, nephropathy).  Presence of peripheral vascular disease.Presence of peripheral vascular disease. ADA Position Statement, Diabetes Care, 2002ADA Position Statement, Diabetes Care, 2002 January 1, 2016January 1, 2016 2525
  • 26. Exercise in DiabetesExercise in Diabetes ExerciseExercise Prescription forPrescription for Special CasesSpecial Cases January 1, 2016January 1, 2016 2626
  • 27. Exercise in DiabetesExercise in Diabetes Diabetic withDiabetic with Peripheral NeuropathyPeripheral Neuropathy Repetitive exercise on insensitive feet canRepetitive exercise on insensitive feet can lead to ulceration & fractureslead to ulceration & fractures.. Peripheral neuropathy may results in lossPeripheral neuropathy may results in loss of sensation in the feet.of sensation in the feet. Limit weight-bearing exerciseLimit weight-bearing exercise (Treadmill,(Treadmill, Prolonged walking, Jogging, Step exercise, etc..)Prolonged walking, Jogging, Step exercise, etc..) Use proper shoes, and always monitor the feetUse proper shoes, and always monitor the feet.. Alternative exercises areAlternative exercises are: Swimming,: Swimming, Bicycling, Arm exercise, Chair exercise, etc..Bicycling, Arm exercise, Chair exercise, etc.. January 1, 2016January 1, 2016 2727
  • 28. Exercise in DiabetesExercise in Diabetes Diabetic withDiabetic with Autonomic NeuropathyAutonomic Neuropathy Hypotension and hypertension are moreHypotension and hypertension are more likely to develop after vigorous exercise.likely to develop after vigorous exercise. This condition may limit exercise capacity &This condition may limit exercise capacity & increase the risk of CV event during exercise.increase the risk of CV event during exercise. Those patients may have difficulty withThose patients may have difficulty with thermoregulation:thermoregulation:  Avoid exercise in hot or cold environments.Avoid exercise in hot or cold environments.  encourage adequate hydration.encourage adequate hydration. January 1, 2016January 1, 2016 2828
  • 29. Hypoglycemia during or after ExerciseHypoglycemia during or after Exercise  It will most likely occur if the patient:  Takes insulin or diabetes pill.  Skips a meal.  Exercises for a long time.  Exercises strenuously. Exercise in DiabetesExercise in Diabetes If it occurs, what can be done?  Patient must eat a snack before exercise, or.  Adjusts the medication dose.  Remember: Patient should always carry a source of CHO with him ( An apple or orange juice, or a piece of fruit). January 1, 2016January 1, 2016 2929
  • 30. Exercise in DiabetesExercise in Diabetes Energy ExpenditureEnergy Expenditure duringduring Physical Activity!Physical Activity! January 1, 2016January 1, 2016 3030
  • 31. ActivityActivity CaloreiCalorei Brisk walkingBrisk walking 0.070.07 RunningRunning (7.5 min per km)(7.5 min per km) 0.130.13 RunningRunning (5 min per km)(5 min per km) 0.2080.208 SwimmingSwimming 0.1620.162 Rope skippingRope skipping (70/min)(70/min) 0.1620.162 Rope skippingRope skipping (80/min)(80/min) 0.1650.165 BadmintonBadminton 0.0970.097 TennisTennis 0.1090.109 SquashSquash 0.2120.212 BasketballBasketball 0.1380.138 Energy Cost of Physical ActivityEnergy Cost of Physical Activity ((kilocalorie/kg. minkilocalorie/kg. min)) McArdle, et., 1991 January 1, 2016 Exercise in Diabetes 31
  • 32. ActivityActivity METMET WalkingWalking (slow)(slow) 2.52.5 Walking (Walking (Brisk)Brisk) 44 RunningRunning (7.5 min per km)(7.5 min per km) 88 SwimmingSwimming 66 Rope skippingRope skipping (slow)(slow) 88 Weight trainingWeight training 66 BadmintonBadminton 4.54.5 TennisTennis (single)(single) 88 SquashSquash 1212 BasketballBasketball 88 Energy Cost of Physical ActivityEnergy Cost of Physical Activity ((METMET)) Ainsworth, et., 2000 January 1, 2016 Exercise in Diabetes 32
  • 33. Exercise in DiabetesExercise in Diabetes How to CalculateHow to Calculate Energy ExpenditureEnergy Expenditure during Brisk Walkingduring Brisk Walking!! January 1, 2016January 1, 2016 3333
  • 34. Exercise in DiabetesExercise in Diabetes == 0.070.07 k.k. caloriecalorie per kg of body weightper kg of body weight // min.min. Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking An Example:An Example: aa person weighing 76 kg would expend:person weighing 76 kg would expend: 0.070.07 X 76 =X 76 = 5.35.3 k.k. calorie per min.calorie per min. January 1, 2016January 1, 2016 3434
  • 35. Exercise in DiabetesExercise in Diabetes Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking  If he has to expend 1200 k.If he has to expend 1200 k. calories per week.calories per week. How much time he should walk per week?How much time he should walk per week?  1200 / 5.3 = 226.4 min.1200 / 5.3 = 226.4 min. = 45 min / 5 days per week, or= 45 min / 5 days per week, or = 57 min / 4 days per week.= 57 min / 4 days per week. January 1, 2016January 1, 2016 3535
  • 36. Preparing For Exercise  Proper warm-up consisting of 5–10 min of aerobic activity  Activity session 15- 30 mins  cool-down should be structured similarly to the warm-up and should last about 5–10 min
  • 37. Types of Physical Activity The Mnemonic: “SAFE” exercises are recommended:  Strengthening exercises  Aerobic exercises  Flexibility exercises  Endurance exercises
  • 38. Aerobic exercise  With Oxygen  Aerobic exercise is the type that moves large muscle groups and causes you to breathe more deeply and your heart to work harder to pump blood. It's also called cardiovascular exercise. It improves the health of your heart and lungs.
  • 39. Anaerobic (Resistance) Exercise  Anaerobic exercise uses large muscles that do not require oxygen for short periods of exercise. It helps build strong muscles; lowers blood glucose makes the action of insulin more effective.
  • 40. Flexibility (Stretching) Exercise  Flexibility exercises are aimed at increasing or maintaining range of motion at joints, also improve tone in muscles and keep it supple. They develop better muscular and body control.
  • 41. Endurance Exercises  Low Resistance, High Repetition Exercises  Examples: Walking, cycling, swimming, or upper extremity ergometry that involve the use of the large muscle of the body.
  • 42. How much exercise? Exercises should be done according to FITT principle.  FREQUENCY: Exercising 4 to 6 times a week.  INTENSITY: 30-40 min of exercise at 50- 60 % of target heart rate.  TYPE: SAFE exercises are recommended.  TIME: Morning is ideal
  • 43. A SAMPLE WALKING PROGRAM Warm Up Target Zone Exercising Cool Down Time Total Week 1 Session A Walk normally 5 min. Then walk briskly 5 min. Then walk normally 5 min. 15 min. Session B --Repeat above pattern-- Session C --Repeat above pattern-- Continue with at least three exercise sessions during each week of the program. If you find a particular week's pattern tiring, repeat it before going on to the next pattern. You do not have to complete the walking program in 12 weeks. Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min. Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min. Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min. Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min. Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min. Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min. Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min. Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min. Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min. Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min. Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min. Week 13 and thereafter: Check your pulse periodically to see if you are exercising within your target zone. As you get more in shape, try exercising within the upper range of your target zone. Gradually increase your brisk walking time to 30 to 60 minutes, three or four times a week.
  • 50. Peripheral and autonomic neuropathy Recommended non-weight- bearing activities swimming bicycling chair and arm exercises Contraindicated treadmill prolonged walking jogging step exercises
  • 51. Nephropathy Recommended Low to moderate intensity forms of exercise Contraindicated High intensity forms of exercise
  • 52. Diabetic retinopathy Recommended  Low-impact cardiovascular conditioning, such as swimming, walking, low-impact aerobics, stationary cycling, endurance exercises Contraindicated  Strenuous activities, pounding or jarring, such as weight lifting, jogging, high-impact aerobics, racquet sports.
  • 53. Hypoglycemia Management The person should be instructed to stop exercising. People at risk for hypoglycemia should always carry a source of glucose with them such as glucose tablets, candy or juice in order to treat hypoglycemia. Remember- it is a medical emergency
  • 54. Snacking to prevent hypoglycemia Basic Rules:  Snack prior to activity to prevent hypoglycemia  Adjust quantity based on pre-activity BG or direction of BG  BG low or dropping:  usual carbs  BG OK or stable: usual carbs  BG High or rising:  usual carbs  Snack at least once per hour during prolonged activity  Choose high-glycemic forms of carbohydrate Source: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
  • 55. Useful Tips For Exercise  Always carry an identification card with you  Check your feet before you walk  Choose good footwear, light clothing  Drink lots of water  Don’t exercise during hot seasons, and when not feeling well
  • 56. What Can Physical Activity Do For You? Give you more energy
  • 57. What Can Physical Activity Do For You? Help you lose weight and keep it off
  • 58. What Can Physical Activity Do For You? Increase flexibility and strength Slow bone loss Provide better quality of life
  • 59. What Can Physical Activity Do For You? Build muscle
  • 60. What Can Physical Activity Do For You? Improve your sex life
  • 61. What Can Physical Activity Do For You? Lift your mood Treat depression
  • 62. What Can Physical Activity Do For You? Reduce stress and anxiety
  • 63. What Can Physical Activity Do For You? Improve blood glucose control (lowers A1C)
  • 64. Physical activity lowers blood glucose in type 2 diabetes by helping:  muscle cells become more sensitive to insulin  keep the liver from producing too much glucose  build more muscle  you lose weight and keep it off
  • 65. What Can Physical Activity Do For You? Keep your heart healthy
  • 66. Physical activity helps your heart by:  Strengthening heart muscle  Lowering resting heart rate  Lowering blood pressure  Improving cholesterol  Reducing risk of heart attack and stroke
  • 67. “Sitting” through life increases your risk of:  heart disease  high blood pressure  high cholesterol  overweight  type 2 diabetes
  • 68. We now must plan physical activity into our schedule
  • 69. Getting Started  Check with your doctor if you:  Are over age 35  Have had diabetes more than 10 years  Have high blood pressure, heart disease, poor circulation, or other diabetes complications
  • 70. Aerobic Activity  Walking briskly  Dancing  Bicycling  Hiking  Jogging/running  Skating  Stair climbing  Swimming  Water exercise
  • 71. Resistance Activities  “Push, Pull, and Lift” Activities  increase muscle strength  prevent falls  increase mobility  improve blood glucose control
  • 72. Stretching  Improves your balance and coordination  Makes you more flexible  Reduces stiffness  Reduces your risk of injury
  • 73. How Can You Begin?  Choose activity (example: brisk walking)  Set a long-term goal - at least 30 minutes a day, 3-5 days a week  Buy comfortable walking shoes  Get a partner
  • 74. Physical Activity Is Like Magic for Type 2 Diabetes
  • 75. Exercise in DiabetesExercise in Diabetes January 1, 2016January 1, 2016 7575

Editor's Notes

  1. Point to discuss: Exercise is ONE of the ingredients that contributes to diabetes management
  2. People with peripheral neuropathy should not undertake weight-bearing exercise. They should be advised to undertake non-weight-bearing exercise such as exercise bike, swimming etc.
  3. Exercise that increases blood pressure, and therefore renal perfusion, is contraindicated in people with nephropathy.
  4. Caution needs to be taken to avoid a bleed in people with significant diabetic retinopathy.
  5. Some people feel like they don’t have enough energy to exercise. But, if you give it a chance, you’ll find that physical activity gives you more energy than you’ve ever had – allowing you to do the things you previously felt you didn’t have enough energy to do.
  6. Exercise boosts your metabolism and helps you burn extra calories, even after you’re done exercising. Exercise combined with eating less can help you lose weight and keep if off. The pounds come off faster and stay off if you add exercise. Even a small amount of weight loss (10-20 lbs) can improve your blood glucose levels if you’re overweight.
  7. Exercise can help you stay independent as you get older. It decreases the risk of muscle and joint injury, aches and pains. It slows bone loss as you age.
  8. We naturally lose muscle as we age. Physical activity helps not only prevent muscle loss, but also build muscle and lose fat.
  9. Studies show that regular physical activity can help prevent some of the sexual problems that can be caused by aging, lack of physical activity, and high blood glucose levels.
  10. Regular physical activity can improve your self-image, make you feel better about yourself, and lift your mood. You can not only make yourself happier, but also those around you. In fact, exercise training has been shown to be comparable to seeing a therapist or taking medication for depression.
  11. Stress and anxiety can lead to overeating. If you overeat as a way to cope with stress, you’ll find that exercise is a better coping mechanism.
  12. If you have type 2 diabetes, exercise can improve your blood glucose control. Let’s look at how it does that.
  13. Physical activity helps your muscles use insulin more efficiently, so you need less insulin. This blood-glucose lowering effect only lasts a few days after exercise, so to get the most out of your exercise, try to do some physical activity every day (or at least 3-5 days a week). Your liver begins making less glucose as it becomes more sensitive to insulin. More muscle means lower glucose. Muscle uses more glucose, even at rest. Exercise helps you lose weight and keep it off. A loss of even 10-20 lbs can really improve your blood glucose. Exercise is also beneficial for type 1 diabetes, but usually does not improve blood glucose control unless insulin and food intake are well balanced with physical activity.
  14. When you have diabetes, you have a much higher risk of heart disease, so exercise is especially beneficial to your heart.
  15. 1. A strong heart does a better job of pumping blood throughout the body. 2. Reducing the resting heart rate and blood pressure put less work on the heart. 3. Exercise lowers total cholesterol, raises HDL (good) cholesterol, and lowers triglycerides 4. All of these help reduce your risk of heart attack and stroke.
  16. Modern technology like elevators, dishwashers, washing machines, remote controls, and computers has eliminated the daily chores and activities of your grandparents era. Inactivity has made us sitting ducks for diseases like heart disease, high blood pressure, high cholesterol and other blood fats, obesity and overweight, and type 2 diabetes. (Ask audience to stop and figure how much time each day is spent sitting and being inactive.)
  17. It’s not a leisure activity that you do only if you have time. It’s necessary if you want to stay healthy.
  18. It’s been said that instead of checking with your doctor to see if you can exercise, people with diabetes should check with their doctor if they are thinking of NOT exercising. It is recommended to find out if you have any limitations (we don’t mean excuses!) and if you should emphasize certain types of activities over others if you are over 35 years old, have had diabetes for more than 10 years, or have certain medical conditions. This does NOT mean you shouldn’t exercise! It simply means talk to your doctor so they can support you in your effort and help you come up with safe and enjoyable ways of increasing your activity level.
  19. When you do activities like walking, mowing the lawn, dancing, swimming, biking, or vacuuming, you use the large muscles in your body in a continuous, repetitive way. These types of activities can improve your health by strengthening your muscles (including your heart), promoting weight loss, reducing blood glucose, and improving your stamina and energy level.
  20. Activities that require pushing, pulling, and lifting – or resistance activities – can help strengthen specific muscles or groups of muscles. They also improve balance and reduce risk of falls, reduce your risk of osteoporosis and bone fracture, increase your energy level and increase your body’s sensitivity to insulin.
  21. You can do stretching anytime, anywhere. Stretching improves your balance and coordination. Stretch during breaks throughout the day and after you complete your exercise during the cool-down to increase flexibility and prevent soreness and injury.
  22. First choose a type of activity that you will enjoy and that’s convenient for you. Walking is the most popular type of exercise and it’s safe for most people to do. If you are unable to walk, you might choose swimming, chair exercises, or water exercises. Set your long-term goal – to get the most benefit from physical activity, it’s recommended to be moderately active at least 30 minutes, 3-5 days a week. Be sure to wear appropriate clothing and shoes for the activity you select. Walking with a partner can help keep you motivated and provide some support. But, don’t rely on a partner who is not totally committed – that can actually be detrimental to your success.
  23. Regular physical activity can do more for type 2 diabetes than any pill could ever do. Like a magic wand, exercise can transform your body, your health and you.