175
A Brief Overview of Diabetes Mellitus
and Exercise
JOHN J. ARMSTRONG, MS
Pro-Form Sports Medicine
St James, New York
While exercise has not been shown
to provide long-term improvements
in blood glucose control, it has been
shown to delay or prevent secondary
conditions associated with diabetes.
Exercise also offers significant
psychological gains by allowing
both IDDMand NIDDMpatients
to participate in normal
recreational or competitive
activities. A properly designed
exercise prescription begins with the
education of the patient, including a
thorough understanding of the
effects of exercise, the demand it
places on the metabolic processes,
and the necessary adjustments that
must be made to maintain
normoglycemia. A stress test is a
recommended preliminary.
Reprint requeststo John J. 4rmstrong, MS. Pro-Form
556-08 North l’ounirj Road. St James. NY I 1780.
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The treatment of diabetes mellitus uses three modalities:
diet, drugs, and exercise. This review will address general
exercise prescription guidelines for individuals who have in-
sulin-dependent diabetes mellitus (IDDM) or non-insulin-
dependent diabetes mellitus (NIDDM). Basic metabolic
and hormonal responses to exercise in normal populations
and in individuals with diabetes mellitus will also be dis-
cussed, as will the benefits gained from exercise for those
who have diabetes.
Goals and Benefits of Exercise
The primary reason for implementing an exercise program
for patients with diabetes is to provide them with the oppor-
tunity to lead a normal active life-style in recreational or
competitive sports. In addition, exercise provides the neces-
sary activity that can prevent or delay long-term pathologies
associated with diabetes. The benefits to be gained from ex-
ercise by those with diabetes are still controversial. The de-
gree of improvement or prevention varies with each
individual and depends upon the duration of the disease
and the state of the person’s metabolic control.
Because studies have not shown long-term improvements
in blood glucose control with exercise, exercise is not gener-
ally prescribed for the sole purpose of reducing blood glucose
levels.’ Nevertheless, studies have demonstrated significant
benefits from exercise in subjects with diabetes who have un-
dertaken a regimented exercise program of appropriate inten-
sity and duration. Exercise can delay or prevent premature
cerebral, coronary, and peripheral vascular diseases that com-
monly occur in diabetic individuals under 30 years of age. 2-4
Furthermore, poor blood lipid profiles associated with diabe-
tes-most often with NIDDM-have been shown to im-
prove with exercise. Reductions in triglyceride, low-density
lipoprotein, and very-low-density lipoprotein levels and in-
creases in high-density lipoprotein levels are commonly noted
with exercise.3 In addition, exercise has been shown to have a
lowering effect on blood pressure. Individuals who become
hypertensive as a result of diabetes or medications used in its
treatment can also reduce this potentially pathological risk
factor with physical activity2
Several specific physiologic improvements in persons with
diabetes have been attributed to exercise. Exercise increases
the number, sensitivity, and binding capacity of insulin recep-
tors, which helps reduce insulin requirements for maintaining
normoglycemia..’4.5 Because hyperinsulinemia appears to be
Sports Medicine.
176
related to vascular diseases and may stimulate arterial smooth
muscle proliferation, accelerating the atherosclerotic process,
a reduction in the need for insulin would decrease the risk for
these pathologies and provide psychological support to the
individual.z2
Diabetes has also been associated with blood coagulation
abnormalities, which contribute to the incidence of cardio-
vascular disease.3 Under these circumstances, which are not
completely understood, fibrinolytic capabilities decrease and
an enhanced ability for platelet aggregation occurs. Studies
suggest that significant improvements in fibrinolytic re-
sponses and other coagulation properties occur with
exercise.;
Energy Metabolism and Hormonal Responses
A general understanding of normal energy metabolism and
hormonal responses during exercise is necessary before an
exercise prescription for an individual with diabetes can be
designed. The regulation of energy sources is a complex and
sensitive system that is primarily monitored and regulated
by the pancreas, which is capable of producing hormones
that play a key role in the regulation of blood glucose levels
and carbohydrate metabolism. Within the pancreas, alpha
cells secrete glucagon, beta cells secrete insulin, and delta
cells secrete somatostatin, all of which effect the delicately
balanced blood glucose level. The major function of these
hormones is to increase the rate ofcellular reactions or trans-
port mechanisms. The primary function of insulin is to facil-
itate the transport of glucose into muscle or adipose cells.
This enhanced transport occurs when insulin attaches to a
specific cell receptor, and blood glucose is carried across the
cell membrane into the cell for energy.’~6 Any glucose that is
not used immediately is stored as glycogen in muscle cells
and as fat in adipose cells.’~6
As blood passes through the pancreas, glucose levels are
monitored. If blood glucose levels are high (hyperglycemia),
insulin is secreted into the blood stream. Insulin will inhibit
the mobilization of fat and the breakdown of glycogen, and
blood glucose will be transported into the cells for use or stor-
age, lowering the glucose levels. On the other hand, if blood
glucose levels are low (hypoglycemia), insulin secretion de-
creases, enhancing fat mobilization and glycogen breakdown
to increase glucose availability and raise blood glucose levels.
This balancing occurs to maintain homeostasis and
normoglycemia. ’.6
Counterregulatory Hormones
A general understanding of the function of the counterregu-
latory hormones glucagon and epinephrine is also necessary
to prescribe exercise for people with diabetes. Glucagon
serves as an &dquo;insulin antagonist&dquo; whose major function is to
increase blood glucose levels. This process is achieved by
glucagon’s stimulating effects on glycogenolysis (the break-
down of glycogen into glucose) in the muscle and gluconeo-
genesis (the production of glucose from noncarbohydrate
sources) in the liver. The enhancement of these two
processes increases the availability of glucose for energy. ’,6
Epinephrine is another counterregulatory hormone that
plays a significant role in the regulation of normoglycemia
during exercise. Epinephrine is released from the adrenal
gland and terminal ends of neurons of the sympathetic ner-
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vous system. It has inhibitory effects on the release of insulin
and facilitates the release ofglucagon.6 As a result, the produc-
tion of glucose is increased and blood glucose levels become
elevated.
These hormones and their combined effects are utilized to
provide fuel to the body upon demand. When the body is at
rest, fat provides the primary fuel source. As energy demand
increases beyond the intensity at which fats can provide fuel
fast enough, the need for glucose or carbohydrate sources in-
creases. Exercise can increase energy demand by more than
10 times the body’s resting values, and the sensitive metabolic
regulatory system must be able to make appropriate adjust-
ments to meet these needs.
With the onset of exercise (and an increase in energy me-
tabolism), cellular glycogen is converted to glucose, and blood
glucose begins to enter the cells more rapidly to meet energy
demand. Concomitantly, an increase in sympathetic nervous
system discharge increases the secretion of glucagon, inhib-
iting insulin secretion and slightly reducing plasma insulin
levels. Glycogenolysis and gluconeogenesis are stimulated,
and glucose production is enhanced. The reduction in insulin
does not disrupt the uptake of appropriate amounts of glucose
into the cells because increased blood flow to the working
muscle transports more of the available insulin to the area for
use, and sensitivity of insulin receptors is also enhanced. Fur-
thermore. increased sympathetic nervous system activity may
have an inhibitory effect upon pancreatic secretion of insulin.
These processes actually lower the requirement for insulin
during exercise and provide the necessary adjustments in glu-
cose production to match peripheral utilization. 1,6-1
Diabetes, Exercise, and Fuel Homeostasis
Fuel homeostasis at rest and during exercise is compro-
mised in individuals with diabetes. Those with IDDM lack
sufficient levels of insulin because of the reduced secretion
of insulin by the beta cells of the pancreas, thus appropriate
amounts of glucose fail to enter the cells, creating a state of
hyperglycemia. Those with NIDDM, on the other hand,
have sufficient levels of insulin but lack the ability to utilize
it because the insulin receptor sites on the cells have become
resistant to the absorption of the insulin and hyperglycemia
results.
Individuals with IDDM offer the greater challenge for pre-
scribing appropriate exercise because their treatment usually
requires some form of insulin supplement. These individuals
must adjust insulin dosage or carbohydrate intake before and
after exercise to maintain normoglycemia during and after
exercise. In IDDM, the most difficult problem encountered
with exercise is for the body to achieve a low but adequate
level of plasma insulin so that glucose can be absorbed into
the cells and produced to meet demand. Therefore, individu-
als with IDDM must be under good metabolic control, with
an established regimen of diet and insulin dosage prior to par-
ticipation in an exercise program so that appropriate manipu-
lations can be made in either insulin dosage or diet to satisfy
the demands of physical activity.
An underestimation of insulin needs before exercise can
create a hypoinsulinemic condition that results in hyperglyce-
mia. Fat metabolism and hepatic glucose production will in-
crease as the body tries to compensate for the reduction in the
uptake ofglucose into the cells. Lack of carbohydrate metabo-
 177

lism under these conditions can result in the formation of ke-

tone bodies that may lead to a disruption in the normal acid
base balance, producing ketoacidosis. When carbohydrate
metabolism by-products are not sufficient for fat metabolism
during beta oxidation, and the breakdown of fat for energy is
incomplete, ketone bodies are formed. Hypoinsulinemia
stimulates glucose production because the regulatory system
detects the reduction in insulin and begins to secrete glucagon
to increase hepatic glucose output. This production of glucose
only worsens the hyperglycemic state. Exercise under these
conditions would inhibit further insulin release because the
counter-regulatory hormones would enhance the production
of glucose even more, intensifying the hyperglycemia. This is
why exercise is not indicated for the purpose of reducing
blood glucose levels; it would only worsen the condition.&dquo;6
Excessive levels of insulin, or hyperinsulinemia, may result
from inappropriately high doses of insulin or the enhanced
absorption rate of insulin by the cell receptors. Under this
condition, transport of glucose into muscular or fat cells is
increased, and the production of glucose is inhibited, creating
a hypoglycemic state that, if prolonged, may interrupt fuel
supply to the brain. This interruption can lead to dizziness,
moodiness, loss of coordination, speech irregularity, and syn-
cope.2 Exercise initiated under these conditions would in-
crease peripheral glucose utilization without increased
glucose production; because insulin levels remain above nor-
mal, hypoglycemia will be exacerbated. Moreover, exercise
can enhance insulin absorption around the injection site, fur-
ther complicating the hypoglycemia.
Hypoglycemia can occur during or after exercise and fre-
quently effects those who have &dquo;brittle&dquo; diabetes, neuropa-
thies, or are taking medication such as 0-adrenergic blocking
drugs. Hypoglycemia following exercise can occur as a result
of glycogen depletion and an increased insulin sensitivity that
causes continued glucose uptake to replete energy stores for
up to 4 to 6 hours after exercise. This response can place the
individual at risk for an unexpected hypoglycemic event.4-1-1
Because it is common for individuals with IDDM to ad-
minister and monitor their own treatment, mismatches in
insulin doses, food intake, activity levels, and changes in ab-
sorption rates due to stress or illness often occur.2 Therefore, it
is essential that those who are responsible for patients’ treat-
ment and monitoring have a thorough understanding of indi-
vidual needs and responses to an exercise program so that a
regimented treatment protocol can be established to elimi-
nate potential abnormal conditions.
General Recommendations
Individuals under the age of 35 who have no pathological
complications resulting from diabetes generally do not re-
quire restrictions in physical activity or a diagnostic exercise
stress test. However, a submaximal exercise test would pro-
vide valuable information of use in developing the exercise
prescription (Table 1 ). These individuals should monitor
blood glucose levels closely to avoid exercise-induced hypo-
glycemia. Those individuals over the age of 35 who have had
diabetes for more than 10 years should have a complete exer-
cise stress test and medical examination.2-3 These are general
recommendations for the use of exercise stress testing and
prescription for those with diabetes; however, such testing
can be indicated for any individual who is beginning an ex-
ercise program, especially for anyone who suffers from
disease.
Recommendations for IDDM Patients Anyone with IDDM
who is going to participate in regular physical activity must
monitor blood glucose levels prior to and following exercise.
If preexercise levels are above 250 mg/dL (13.9 mmoUL),
exercise should be postponed until the glucose level drops
below this value
Each individual will establish unique modifications in in-
sulin dosage, caloric intake before and after exercise, and
physical activity levels that will maintain normoglycemia.
The most adequate method can be found only through trial
and error, so that a lower but appropriate level of plasma insu-
lin can be reached while maintaining sufficient levels of glu-
cose. Generally, under the supervision of their physician,
individuals can increase the intake of easily absorbed carbo-
hydrates approximately 15 to 30 minutes before exercise if
blood glucose levels are in a normal range of 70 to 125 mg/dL
(3.9 to 6.9 mmoUL), or they can reduce the dose of intermedi-
ate-acting insulin by 30% to 35% on the day of exercise or
omit the dose of short-acting insulin prior to exercise. A com-
bination of the two methods can be implemented, such as re-
ducing the short-acting insulin dose by 30% to 35% and
consuming carbohydrates prior to exercise. Once exercise has
started, 15 to 30 grams of carbohydrate should be eaten every
30 minutes during exercise. Following exercise, more slowly
absorbed carbohydrates should be consumed to prevent
delayed postexercise hypoglycemia (Table 2). In addition, ad-
equate amounts of fluids should be consumed before, during,
and after exercise. Persons with diabetes are predisposed to
dehydration because hyperglycemia increases the require-
ment for fluid for urine production. This consideration is es-
pecially important for those with autonomic neuropathy.&dquo;6
Insulin injection sites should be changed from exercising
muscles. Exercise should not begin until 60 to 90 minutes af-
ter injection or until peak insulin action has been reached.2..’

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178

dietary manipulations. In addition, exercise studies suggest

that conditionscommonly associated with NIDDM, such as
obesity, hyperlipidemia, and hypertension, can be improved
with physical activity.’-’ Similar findings have been noted by
E. S. Horton and N. S. Ruderman.

Summary
The treatment of diabetes is a complex procedure that in-
cludes several methods and combinations of techniques to
achieve appropriate levels of blood glucose for normal en-
ergy metabolism and to reduce secondary complications. It
is essential for physicians, health professionals, and patients
to have open lines of communication with one another so
that an effective treatment plan can be designed.
The use of exercise in the treatment of IDDM and NIDDM
Special Considerations IDDM patients with microvascular appears to benefit individuals
by delaying or preventing
complications such as proliferative retinopathy or nephro- pathologies associated with the disease and allowing them to
pathy should avoid high-intensity activity that elevates sys- lead a normal active life-style. A properly designed exercise
tolic blood pressure above 180 to 200 mm Hg for substantial prescription begins with the education of the patient. A thor-
periods of time. The exercise prescription for these individ- ough understanding of the effects of exercise, the demand it
uals should take into consideration their blood pressure places on the metabolic processes, along with the necessary
responses adjustments that must be made to maintain normoglycemia,
Individuals with peripheral neuropathy experience loss of are necessary for a safe and effective treatment protocol.
sensory function, and they should avoid traumatic full- A formal exercise prescription should be preceded by a
weight-bearing exercise. Their mode of activity should be lim- complete stress test used for diagnostic purposes in those over
ited to cycling or swimming, for example. Furthermore, the age of 35 or for functional measurements for those under
proper shoes and socks should be worn during exercise, and 35. Once a regimented daily and weekly treatment plan has
the feet must be examined frequently2J been designed and appropriate mode, intensity, frequency,
Neurological complications such as autonomic neuropathy and duration of exercise established, individuals can begin to
will impair normal sympathetic and parasympathetic func- make slight variations in the protocols to enhance their active
tion. Cardiovascular responses such as decreased exercising daily living, thus helping them to lead normal, healthier lives.
heart rate, hypotension, irregular thermoregulation, and diffi-
culty sensing the signs of hypoglycemia are common clinical I would like to thank the staff at Pro-Form for their support and assistance
signs. Proper exercise prescription and supervision for these throughout the development of this manuscript and especially thank
individuals are essential.2J Peggy Ann Herzberg, RN. AT, for her support and guidance.

Recommendations for NIDDM Patients The regulation of

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