Physiotherapist
Department of PMR,
CMC, Vellore
Nutrition
EXERCISE
Medication
“Exercise is the best insulin sensitizer on
the market; better than any medication
we currently have available"
Bartol
During the first few minutes of exercise:
Glycogen in the muscles is broken down
anaerobically
After 5-10 minutes of activity:
Muscle glycogen breakdown decreases.
Glucose broken down in the liver is released
into the blood stream and is taken up by the
muscles as fuel. This glucose becomes the
major source of fuel (hepatic glycogenolysis).
At 20 minutes or more:
The muscles’ glycogen stores are now
depleted. Blood glucose is now maintained
by hepatic glycogenolysis and triglycerides
that are broken down from adipose tissue. As
exercise continues fat breaks down to free
fatty acids (FFA) and is used as a source of
fuel for the muscles, through the process of
hepatic gluconeogenesis rather than hepatic
glycogenolysis.
Longer duration of exercise:
Should low-to-moderately Increase the risk of DKA in a
intensive exercise continue person who is insulin deficient;
for a long period of time, such as Type I with elevated
the muscles will continue blood glucose.
to use the glucose derived
from hepatic If carbohydrate is consumed
gluconeogenesis. during exercise, the decrease in
blood glucose can be delayed
FFA cannot completely and the exercise can be sustained
replace the use of glucose for a longer period. This is often
and if carbohydrates are done by people with diabetes
limited, then ketone who are marathon runners or
bodies may form. engage in moderate to intensive
exercise for long periods of time.
SHIFT IN FUEL USAGE
N E F A ‘S
Muscle Glycogen
EXERCISE INSULIN
GLUCAGON AMINO ACID
METABOLISM &
FAT OXIDATION
INTENSE AEROBIC EXERCISES
NOREPINEPHRINE & EPINEPHRINE
LEVELS
15 FOLD GLUCOSE
PRODUCTION
RISES 7 FOLD
Improves overall blood glucose control and HBA1c
levels in type 2 diabetes.
Improves insulin sensitivity and lowered insulin
requirements often leading to a reduced dosage of
insulin and or oral hypoglycaemic agents especially
in people with Type 2 diabetes.
Attainment and maintenance of ideal body
weight.
Reduction of coronary risk factors
Favorable changes in body composition
(decreased body fat and weight, increase in muscle
mass).
Lowers cardiovascular and overall mortality.
In the acute phase, exercise results in
translocation of glucose transporters to the
plasma membrane and increased glucose
uptake
With prolonged exercise there is up
regulation of glucose transporter numbers,
changes in capillary density which overall
causes an improvement in insulin sensitivity.
Even short-term (2-week), regular aerobic
exercise in type 2 diabetic patients results in
significant improvement in both aerobic
capacity and whole-body insulin sensitivity.
Long-term endurance training in diabetic
patients markedly improves whole-body insulin
sensitivity and the expression of key muscle
enzymes regulated by insulin. However, the
maintenance of this effect seems to require
dedication to a regular and uninterrupted
exercise regimen.
Intramyocellular lipid accumulation, which is
associated with insulin resistance in muscle, can
be acutely decreased by even a single bout of
sustained endurance exercise.
Exercise is beneficial for both glucose uptake
mechanisms and the anti-lipolytic effects of
insulin.
Cardiovascular
Microvascular
Metabolic
Musculoskeletal and traumatic
Cardiac Dysfunction
and Arrythmias due to
silent IHD
Excessive increments
in Blood pressure
Post Exercise
Orthostatic
hypotension
Retinal Haemorrhage
Increased proteinuria
Acceleration of other
microvascular lesions
Worsening of
Hyperglycemia and
ketosis
Hypoglycemia
Foot ulcers
Accelerated
degeneration of joints
EVALUATION OF A
PATIENT BEFORE
EXERCISES
Exercise ECG
Borg’s Rate of Perceived
Exertion
Karvonyn’s Formula
MHR = 220-AGE
HRR = MHR-RHR
EHR = 50-60 X HRR + RHR
100
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
The Mnemonic: “SAFE” exercises are
recommended:
Strengthening exercises
Aerobic exercises
Flexibility exercises
Endurance exercises
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 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 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.
Low Resistance, High
Repetition Exercises
Examples:
Walking, cycling,
swimming, or upper
extremity ergometry
that involve the use of
the large muscle of the
body.
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
Target Zone Exercising
Warm Up Cool Down Time Total
*
Week 1
Then walk normally 5
Session A Walk normally 5 min. Then walk briskly 5 min. 15 min.
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.
Recommended Contraindicated
non-weight-bearing treadmill
activities
prolonged walking
swimming
jogging
bicycling
step exercises
chair and arm
exercises
Recommended Contraindicated
Low to moderate High intensity
intensity forms of forms of exercise
exercise
Recommended Contraindicated
Low-impact Strenuous activities,
cardiovascular pounding or jarring,
conditioning, such as such as weight lifting,
swimming, walking, jogging, high-impact
low-impact aerobics, aerobics, racquet
stationary cycling, sports.
endurance exercises
The person should be instructed to stop
exercising. People at risk for hypoglycaemia
should always carry a source of glucose with
them such as glucose tablets, candy or juice
in order to treat hypoglycaemia.
Remember it is a medical
emergency
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
250
200
Big snack prior
BG (mg/dl)
(rise & crash)
150 Snack q 40
minutes
100
50
Pre-Ex 20m 40m 1hr 1h 1h Post-
20m 40m Ex
Source: Scheiner, Gary, MS CDE
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
Physical activity should be encouraged in
all people with diabetes
People need to be educated about
prevention and treatment of
hypoglycaemia
People should be taught to plan for
periods of physical activity
Thank you
