1) Regular moderate exercise of at least 150 minutes per week can reduce the risk of developing diabetes in people who are predisposed. 2) Exercise improves physical fitness and cardiovascular health as well as glucose control for those with type 1 or type 2 diabetes. It works by increasing insulin sensitivity and glucose transporters. 3) An exercise prescription for diabetics includes 30-60 minutes per day of aerobic activity, moderate weight training 2 times per week, monitoring heart rate and blood glucose levels, and gradual progression of intensity over time.

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
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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.
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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
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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
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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
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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
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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.
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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.
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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.
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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
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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..
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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.
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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).
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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!!
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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.
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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.
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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.

44. Breathing Exercises

45. Neck Exercises

46. Hand Exercises

47. Trunk Exercises

48. Trunk Exercises…………

49. Leg Exercises

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