1. Exercise is important for managing diabetes as it reduces insulin resistance, lowers blood sugar, and improves heart health. 2. During exercise, muscles initially use glycogen stores and glucose for fuel, then fatty acids are used for longer duration exercise. Regular exercise increases insulin sensitivity. 3. Benefits of exercise for diabetics include better glycemic control, reduced insulin resistance, lower blood pressure and improved cholesterol. Walking is a good exercise option as it has cardiovascular benefits and requires no equipment.

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ROLE OF EXERCISE IN
DIABETES
BY
DR.MOHAMMED MUSSY

2. INTRODUCTION:
Activity keeps you going, reduce insulin
resistance, With GLUT-4 glucose moves
with persistence, It's not just the sugar
that drops when you bend, But the heart
beats better so you're fit till the end.

3. PHYSIOLOGICAL CHANGES OCCURING DURING EXERCISE
• DURING FIRST FEW MINUTES IF EXERCISE :Glycogen in the muscles is broken down anaerobically and used as fuel by muscles.
As the physical activity continues, oxygen becomes available aerobic break down of carbohydrates, fats, and proteins. In
addition muscle takes up the glucose in the circulation With Glut-4.
• After 5-10 minutes of activity: Muscle glycogen break down decreases. Decrease in the blood glucose suppresses insulin and
stimulates glucagon, causes hepatic glycogenolysis and glucose is released into blood and taken up by muscles as fuel.
• At 20 minutes or more: Muscle glycogen stores are now depleted. counter regulatory hormones other than glucagon
(cortisol, epinephrine, norepinephrine, and growth hormone) play an increasing role. Epinephrine and norepinephrine
stimulate lipolysis and the resulting triglycerides break down into free fatty acids (FFAS) and glycerol and used as a source of
fuel by muscles and glycerol can be converted into glucose by hepatic gluconeogenesis.
• Longer duration of exercise: muscles will continue to use the glucose from hepatic gluconeogenesis and FFA, as the fuel. FFA
cannot completely replace the use of glucose and if carbohydrates are limited, then ketone bodies may form and
increases risk of diabetic ketoacidosis in a person who is insulin deficient such as type 1 diabetic with poor glycemic control. If
a carbohydrate snack is consumed during exercise, the decrease in blood glucose can be delayed and the exercise can be
sustained for a longer period. This is often done by people with diabetes who are marathon runners or those who engage in
moderate to intensive exercise for long periods of time.
• Long-term training: On a regular, long-term basis, moderate aerobic exercise increases the quantity of mitochondrial enzymes
and the development of new muscle capillaries and also increased translocation of insulin-responsive glucose transporters to
the muscle membrane.

4. BENEFITS
OF
EXERCISE IN
PATIENTS
WITH
DIABETES
Glycemic control
Decreases insulin resistance
Reduction in bp
Improvement in dyslipidemia
Increased vascular reactivity
Reduction in CV events
Psychological well being

5. Potential adverse
effects of exercise
in
diabetic patients
Cardiovascular
1.Cardiac dysfunction and arrhythmia due to
silent ischemia
2.Excessive increments in blood pressure
3. Exercise induced orthostatic hypotension.
Microvascular
1.Retinal hemorrhage
2.Increased proteinuria
Metabolic
1.Worsening of hyperglycemia and ketosis
2.Hypoglycemia.
Musculoskeletal
1.Foot ulcers
2.Accelerated degeneration of joints.

6. Exercise
prescription

7. Exercise prescription
includes:
1. Warm-up period: 5-10 minutes of aerobic
activity such as walking or bicycling at low
intensity. This is to prepare the muscles, heart,
and lungs for the forthcoming intensive activity.
2. Period of intense exercise
3. Cool-down period: Occurs following the
period of intense exercise. should last for 5-10
minutes and consists of the same activities as
the warm-up. The purpose is to gradually bring
the heart rate down to the pre-exercise level.
4. Plan to increase intensity or duration of
activity over time.

8. Warm-up and
cool-down
exercises

9. Tips to start a walking program
Wear shoes with proper arch support, a firm heel, and thick flexible soles
that will cushion your feet and absorb shock.
Wear clothes that will keep you dry and comfortable. Begin walking faster,
farther, and walking for longer periods of time over several weeks
Set goals and rewards.
"THE MORE YOU WALK THE BETTER YOU FEEL AND MORE THE CALORIES
YOU BURN".

11. Reducing sedentary activities
• Sedentary activities are physical activities undertaken when awake that have very low
energy expenditure. These include working at a table or on a console ,watching television
and reading on a couch. Over a period of time these are associated with mortality and
morbidity independent of exercise undertaken later. Poorer glycemic control is seen in
patients with diabetes who spend a longer time in sedentary activities.
• Current recommendations to reduce sedentary times include:
• All diabetics should make effort to reduce sedentary activities.
• Prolonged sitting should be interrupted by briefbouts of standing or ambulation (<5
minutes) every 20-30 minutes. This strategy has been shown to improve glycemic control
in sedentary patients with type 2 diabetes.
• In patients with type 2 diabetes in addition to interrupting sitting for more than 30
minutes, 15 minutes of light walking post meals contributes to improvement in glycemic
control.

12. EXERCISE IN
CHILDREN

13. EXERCISE IN DIABETIC PREGNANTS
1 Women with diabetes who exercise excessively may suffer from hypothalamic amenorrhea or
oligomenorrhea. These women should be encouraged to stop exercising or reduce the amount of exercise.
2. Women with diabetes who undertake moderate-intensity exercise should be encouraged to continue with
the same as they try and achieve their preconceptional targets.
3. Women who regularly do not exercise and have normal body weight do not appear to benefit from an
exercise program
4. Women who are overweight should be encouraged to undertake moderate-intensity exercise as part of their
preconceptional planning of treatment.
5. In pregnancy moderate exercise is recommended if there are no obstetric contraindication.

14. TYPES OF
PHYSICAL ACTIVITY
The mnemonic: "SAFE" exercises are
recommended:
Strengthening exercises.
Aerobic exercises.
Flexibility exercises.
Endurance exercises.

15. • Strengthening Exercises :
use muscular strength to move a weight or work against a
resistive load.
Examples : weight lifting and exercises using weight machines.
exercise increases muscular fitness .
• Aerobic Exercises :
uses large muscle groups and requires oxygen for sustained
periods. consists of rhythmic, repeated, and continuous
movements of the large muscle groups. A total time of about 30-
45 minutes a day at least 5 days a week is recommended for
most people. Thirty minutes of exercise does not have to be
done at a stretch. Walking for 10 minutes in the morning, 10
minutes at lunch, and 10 minutes in the evening can have the
same benefit.
Examples : walking, bicycling, jogging, continuous swimming,
water aerobics, and many of the sports activities. When
performed at sufficient intensity and frequency, this type of
exercise increases cardiorespiratory fitness.

16. • Flexibility (Stretching) Exercises :
• Flexibility exercises are aimed at increasing or
maintaining range of motion at joints, also
improve tone in muscles, and keep it supple.
They help in developing better muscular and
body control.
• Duration: One should start by holding a stretch
for 10 seconds. With practice, one can
comfortably hold a stretch for up to 60 seconds.
• Frequency: A person can plan to do these
exercises at least five times a week.
• Endurance Exercises :
refers to the ability to perform low-intensity,
repetitive, or sustained activities over a prolonged
period of time. such as walking, cycling swimming
etc..,

17. • Nonweight-bearing Exercises:
• Weight-bearing exercises may be difficult for some individuals
with significant obesity (body mass index>35 kg/m²)
and those with associated joint degeneration. For these
individuals nonweight-bearing moderate-intensity physical
activity should be encouraged.
• include stationary cycling, recumbent cycling, seated
stepping, upper body ergometry, and seated aerobics. In
patients with access to a swimming pool, regular swimming,
and water aerobics are other excellent choices.

19. Exercises should be done according to the FITT principles:
Frequency: Exercising daily is preferred or at the least four times a
week and not allowing more than 2 days to elapse between
sessions.
Intensity: 30-40 minutes of exercise at 50-80% of target heart rate.
Type: Safe exercises are recommended.
Time: Morning is ideal.

20. • Which is the Best Exercise?
• The best exercise is the one that
your patient will stick to.
• Walking is considered one of the
best choices because it is easy,
safe, and cheap. And it does not
require any training or special
equipment, except for good shoes.
Walking is an aerobic and weight-
bearing exercise, so it is good for
the heart and helps prevent
osteoporosis.

21. Summary