The document discusses guidelines for exercise in diabetes management, including the various types of exercises like aerobic, resistance, flexibility and balance exercises. It provides recommendations for assessing patients' fitness levels before exercise and monitoring them during physical activity. The document also outlines benefits and risks of exercise for people with diabetes, and strategies to help patients overcome barriers to regular physical activity.

1. Postgraduate Diploma in Diabetes
Education (PDDE
lec 1 Nutrition therapy: Diabetes
Mellitus and physical activates
Prepared by;
Dr. Siham M.O. Gritly
Dr. Diham Mohamed Osman Gritly
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2. Objectives
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the participant will be able to:
Describe the benefits of exercising.
Describe the different types of exercise.
Identify the risks of exercise for people with diabetes.
Give recommendations for exercising.
Know how to assess the person with diabetes before
the exercise session.
• Monitor the person with diabetes during the exercise
session.
• Recognize that individuals have barriers to exercise.
• Give recommendations for particular cases
Dr. Diham Mohamed Osman Gritly
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3. glossary
• Physical activity; Bodily movement produced by the
contraction of skeletal muscle that requires energy
expenditure in excess of resting energy expenditure.
includes cardiorespiratory fitness, muscular
fitness, and flexibility
• Exercise; A subset of physical activity:
planned, structured, and repetitive bodily movement
performed to improve or maintain one or more
components of physical fitness
(Strength, Power, Balance, Flexibility, Cardiovascular
Endurance, Local Muscle Endurance, Strength
Endurance
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4. • Physical fitness is ―a set of abilities
individuals possess to perform specific types
of physical activities
• Fitness is the state or conditions of being
healthy, or good health and condition as a
result of exercise and balance nutrition
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5. • Maximal oxygen consumption (VO2); is An
important measure of sports fitness; aerobic
capacity, where the amount of oxygen body can
consume and turn into energy
• -respiratory quotient (RQ) -is the ratio of
carbon dioxide expired/moles of oxygen
consumed or the ratio of oxygen used in
metabolism (and therefore heat generated), to
carbon dioxide eliminated)
• The respiratory quotient (RQ) is calculated from
the ratio: RQ = CO2 eliminated / O2 consumed
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6. Diabetes Mellitus and physical
activates
• Physical activity (exercise) is an important
component of diabetes management with
physiological and psychological benefits.
• Regular exercise is highly recommended for
many people who have either Type 1 or Type 2
Diabetes Mellitus (DM).
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7. • physical exercise and balance nutrition provide
better performance; including:
• -Cardiovascular health (blood flow, blood
pressure and oxygen delivery)
• -Respiratory function
• -Hormones
• -Immune response
• -Muscles and bones
• -Metabolism
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8. Health professional recommended physical
activity program including
• 1-Aerobic exercise provides health benefits;
moderate physical activity about 30 minutes or
three 10-minutes exercise daily is recommended
by most of the fitness professionals
• 2-resistance exercise; exercise that increase
muscular strength and endurance is
recommended. 8-10 exercises that stress the major
muscle group of the body at least twice a week
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9. • 3-flexibility and balance exercise; activities
that help increase flexibility 2 days a week for
10 minutes is recommended
• 4-exercise programs especially design for
older individual should based on physical
fitness level and health status
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10. Types of exercises
aerobic exercises
Aerobic exercise; consists of
rhythmic, repeated, and
continuous movements of the
same large muscle groups for at
least 10 min at a time. Examples
include
walking, bicycling, jogging, cont
inuous swimming, water
aerobics, and many sports. When
performed at sufficient intensity
and frequency, this type of
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exercise increases
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11. Intensity of aerobic exercise
Intensity of aerobic exercise.
This will be described as
―moderate‖ when it is at 40–
60% of V̇o2max (∼50–70% of
maximum heart rate) and
―vigorous‖ when it is at
>60% of V̇o2max (>70% of
maximum heart rate).
“Resting heart rate averages
60 to 80 beats/min in healthy
adults”
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12. Maximum oxygen consumption V̇o2max
An important measure of sports fitness is
aerobic capacity or VO2 max, which is
the amount of oxygen your body can
consume and turn into energy.
Maximum oxygen consumption;-VO2 is
the Ability to Deliver and Use Oxygen
• As work rate is increased, oxygen
uptake increases linearly, No further
increase in VO2 with increasing work
rate
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13. Cardiorespiratory fitness (also known as
cardiorespiratory endurance or aerobic
fitness
The ability of the circulatory and
respiratory systems to supply
oxygen during sustained physical
activity. The standard for
measurement of cardiorespiratory
fitness is a test of maximal oxygen
uptake (V̇o2max), using indirect
calorimetry on a treadmill or
bicycle ergometer
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14. Anaerobic exercises
Anaerobic exercises may last only
two minutes or less, but this type of
workout actually burns more calories
than aerobic exercise.
Unlike aerobic exercise, anaerobic
exercise burns a higher percentage
of calories from glycogen
These are less adapted to the needs
of most people with diabetes
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15. Anaerobic exercise include, strengthbased activities, such as sprinting or
bodybuilding
Anaerobic exercise is high in
intensity and short in duration
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16. Resistance exercise.
• Resistance exercise.
• Activities that use muscular strength and
endurance to move a weight or work against a
load.
• Examples include weight lifting and exercises
using weight machines. ‗When performed with
regularity and moderate to high
intensity, resistance exercise increases
muscular fitness’.
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17. Muscular Strength; tests muscular strength of the upper
body, (Push Up Strength Test), or Muscular Endurance which
tests the ability of the muscles to exert force over an extended
period of time
Muscular fitness.This refers to
strength (the amount of force a
muscle can exert) and muscular
endurance (the ability of the muscle
to continue to perform without
fatigue)
Muscular endurance is assessed by
counting the maximum number of
repetitions of a muscular contraction a
person can perform to fatigue
(Repetition Maximum Testing 1 RM)
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18. Flexibility and balance exercise.
This term refers to the range of motion available at
joints.
Flexibility; the capacity of
the joints to move through
a full range of motion; the
ability to bend and recover
without injury
Flexibility is an important
component of fitness and
physical performance
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19. • stretching for 5 to 10 minutes helps your body
warm up and get ready for activities and cool
down afterwards
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20. The benefits of exercise for diabetic
patients
• Improves cardiovascular fitness in type 1 and 2
diabetes.
• Reduces cardiovascular risk factors, such as
hypertension and hyperlipidaemia in type 1 and 2
diabetes.
• Contributes to the flexibility, endurance, and
muscle strength.
• Improves glucose control in type 2 diabetes.
• Increases peripheral use of glucose.
• Decreases glucose hepatic output.
• Increases insulin sensitivity
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21. • Decreases counter regulatory hormones.
A counter regulatory hormone is a hormone that
opposes the action of another.
• Helps maintaining weight in addition to meal
planning among people with type 2 diabetes
whose weight is normal, and helps to reduce
weight in obese people.
• Gives a sense of well being and a better quality
of life in people with types 1 and 2 diabetes.
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22. What are the risks of exercise for people
with diabetes?
• Developing hypoglycaemia during or after
exercise, especially in a person on insulin.
• Increased hyperglycaemia in poorly controlled
persons and under-insulinised persons with
pre-exercise blood glucose levels of 250-300
mg/dl (14-17 mmol/l).
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23. • Myocardial infarction or arrhythmia in persons
with diabetes who also have atherosclerotic
disease, if exercise is not properly paced.
• Possible worsening of microvascular diabetes
complications especially retinopathy
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24. • Damage to soft tissue/joints in the presence of
peripheral neuropathy.
• Damage to the feet, when not wearing the
proper shoes
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25. Recommendations for exercising
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Adequate fluid intake during exercise.
Use of proper footwear.
Wearing an identification bracelet.
Avoidance of exercise in extreme temperatures
(heat or cold).
• Inspection of feet after exercise.
• If possible, exercise with a friend.
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26. Recommendations For type 1 diabetes
• Individuals with type 1 diabetes should avoid
exercise if fasting blood glucose is higher than
250 mg/dl and ketones are present.
• recommendation can be made for hypoglycaemia
prevention and improving metabolic control.
• self-monitoring of blood glucose needs to be
integrated into the exercise programme and the
information to be used to adjust the insulin
dosage and food intake
• Increase intake of carbohydrates if glucose levels
are < 100 mg/dl
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27. General recommendations for type 2
diabetes:
• Individuals with type 2 diabetes should avoid exercise if
blood glucose is higher than 400 mg/dl.
• Monitoring blood glucose before, after and during
physical activity is necessary to keep blood glucose
within an appropriate range.
• Frequency: at least 3 days per week.
• Duration: according to the individual.
• Intensity: 50-70% of person’s maximal heart rate
(maximum heart rate = 200-age)
• heart rate averages 60 to 80 beats/min in healthy adults
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28. • People using hypoglycaemic agents or insulin
should self-monitor their blood glucose to
determine glycaemic response to exercise.
• They should adhere to the recommended
different phases of exercise as follows:
• Warm-up: 10 - 15 minutes
• Actual exercise: 30 - 45 minutes
• Cool down: 5 - 10 minutes.
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29. •
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Insulin administration
Avoid exercise during peak insulin action.
Reduce insulin dose if exercise is anticipated.
Administer insulin away from the working
limbs.
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30. Exercise is highly recommended—for most people with
type 2 diabetes, including those with complications.
A person with type 2
diabetes can use
exercise to help
control their blood
sugar levels and
provide energy their
muscles need to
function throughout
the day.
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31. What is Fitness Assessment
• fitness assessment provide an accurate measure
of the current fitness and health level of an
individual
• A fitness assessment provides a baseline
measurement of
• 1-cardiovascular endurance,
• 2- body composition,
• 3- muscular endurance,
• 4-muscular strength
• 5- flexibility.
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32. Assessment of the person with diabetes
before exercise
• History and physical examination
• They must detect diseases of the heart, blood
vessels, eyes, kidneys, and nervous systems
• Persons with diabetes especially at risk
must have a more detailed medical
examination. This includes people:
• aged > 35 years
• with type 2 diabetes for longer than 10 years
• with type 1 diabetes for longer than 5
years
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33. • with any additional risk factors for coronary
heart disease.
• with microvascular disease
(retinopathy, nephropathy).
• with peripheral vascular disease, autonomic
neuropathy.
• Always examine feet and footwear.
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34. • Basic tests
• These can be done depending on the individual
situation
• Cardiovascular system: ECG, exercise ECG.
• Peripheral arterial disease: toe pressure, ankle
Doppler
• Retina: retina screening (fundoscopy)
• Kidneys: urine microprotein
• Peripheral neuropathy test: 10 g monofilament
test.
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35. Monitoring during exercise
• 1. Metabolic control before physical activity
• Avoid exercise if fasting level is > 250 mg/dl
(14 mmol/l) and urine ketones present, or
• if > 16.6 mmol/l irrespective of whether
ketosis is present.
• Increase intake of carbohydrates if glucose
levels are < 100 mg/dl (6 mmol/l).
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36. • 2. Blood glucose monitoring before and after
physical activity
– Identify when changes in insulin or food in take
are necessary.
– Gain knowledge of the glycaemic response to
different exercise/physical activity conditions.
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37. • 3-Food intake
– Consume added carbohydrates as needed for
avoiding hypoglycaemia.
• Carbohydrate-based food should be readily
available during and after exercise, e.g. Fresh
juice, commercially available high-energy
drinks
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38. • 4- Insulin administration
– Avoid exercise during peak insulin action.
– Reduce insulin dose if exercise is anticipated.
– Administer insulin away from the working limbs.
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39. Barriers to exercise
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Barriers may be real, e.g.
lack of motivation,
presence of debilitating illness,
physical disability, e.g. polio, blindness, lack
of available space, time, and security.
• foot problems,
• neuropathy.
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40. •
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There may also be perceived barriers, such as;
having to go to the gym,
exercising being expensive
and a waste of time,
not liking it or being tired.
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41. How to help patient to overcome barriers
• Encourage group exercising.
• Allow the person with diabetes to choose what
he/she likes and can afford to do.
• Discuss with the person and agree about a
specific target, such as walking 30 minutes every
day, and so on.
• Explain that simple, regular exercise is possible in
most cases, such as walking, climbing
stairs, going uphill, and even the usual daily
chores that can be organised.
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42. • Show a few exercises that the elderly people
can perform regularly every day.
• In young people, playing football or
basketball, doing gym in a group, or jogging
are suitable suggestions
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43. Recommendation in particular
situation
• Exercises for people with retinopathy
• Diabetic retinopathy is a complication of diabetes that
affects the eyes. It's caused by damage to the blood
vessels of the light-sensitive tissue at the back of the
eye (retina).
• Not recommended: excessive jogging, high-impact
aerobics, weight lifting, and boxing.
• Recommended: mild exercises, such as walking, lowimpact aerobics, and endurance exercising
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44. • Exercises for people with nephropathy
• nephropathy loss of protein in the urine, and
eventually chronic kidney disease requiring dialysis .
• Moderate exercise is allowed (working at 65% of heart
rate).
• Heart Rate; Resting heart rate averages 60 to 80
beats/min in healthy adults. In sedentary, middle aged
individuals it may be as high as 100 beats/min. In elite
endurance athletes heart rates as low as 28 to 40
beats/min
• In overt nephropathy: exercise is self-limiting.
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45. • Exercise for people with current or previous
foot disease, Charcot’s arthropathy:
• No weight-bearing exercises.
• Avoid repetitive exercises, e.g. prolonged
walking, jogging, step exercises.
• Recommended: swimming, bicycling, rowing, chair
exercises, and arm exercises.
• Amputees can do exercise in a wheel chair, with arms
and body.
• In case of arthritis or arthrosis: mild exercising, e.g.
walking, relaxed gym.
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46. • Exercise in children
• Encourage them to do regular physical
activity, such as sport, outdoor
play, football, gym.
• Pay attention to the need of balancing glycaemic
control with normal playing.
• To achieve control, parents, teachers, and
caregivers have to work together.
• Hormonal changes in adolescents may
complicate control
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47. • Exercise in the elderly
• Advancing age and obesity may hinder aerobic
exercising.
• Encourage mild exercise, e.g. walking
regularly.
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48. references
• American Diabetes Association. 2002. Diabetes and Physical
activity. Position statements: Diabetes Care, 26 (suppl
1):73S.
• Fitness Instruction Manual. 2001. Academy Vocational
Training
• Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C.
2004. Physical Activity/Exercise and Type 2 Diabetes.
Diabetes Care 27: 2518-2539.
• American Diabetes Association (2002). Clinical Practice
Recommendations:2002. Diabetes Care 25 (suppl. 1):S64S68.
• Sareen Gropper, Jack Smith and James Groff, Advanced
Nutrition and Human Metabolism, fifth ed.
WADSWORTH
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49. • Melvin H Williams 2010; Nutrition for Health, Fitness
and Sport. 9th ed, McGraw Hill
Heymsfield, SB.; Baumgartner N.; Richard and SheauFang P. 1999. Modern Nutrition in Health and
Disease; Shils E Maurice, Olson A. James, Shike
Moshe and Ross A. Catharine eds. 9th edition
• Guyton, C. Arthur. 1985. Textbook of Medical
Physiology. 6th edition, W.B. Company
• http://www.livestrong.com/article/500155-exampleof-anaerobic-exercise/#ixzz2S1NYa5jd
•
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