EXERCISE PRESCRIPTION

IN DIABETES MILLETUS
 BY
HETAL PAGHDAR
UNDER GUIDANCE OF
Dr. PRAJAKTA PATIL (PT)
 CONTENTS
• Introduction • Importance of exercise
• Synthesis and action of in DM
insulin • Exercise testing
• Types of DM • Exercise prescription
• Pathogenesis of T1DM • General Considerations
and T2DM • Special conditions/
• Diagnosis complications
• Management • Pre diabetes
• Metabolic syndrome
 INTRODUCTION
• Diabetes Milletus (DM) is a group of metabolic
diseases due defects in insulin secretion
and/or inability to use insulin.(1)
• China and India have the highest number of
individuals with DM in whole world.
• According to WHO India has 69.2 million
people living with diabetes.
• J.E.Shaw et al n their study Global estimates of
prevalence of diabetes for 2010 and 2030
stated that: the world prevalence of diabetes
among adults(20-79 years) will be 6.4% i.e.
affecting 285 million adults in 2010 and
increase to 7.7% i.e. 439 million by 2030,
there will be 69% increase in developing
countries and 20% in developed countries.
• WHO quoted “diabetes is a growing challenge
in India with estimated 8.7% diabetic
population in the age group f 20-70 years. This
rising prevalence is driven by combination of
factors- rapid urbanization, sedentary
lifestyles, unhealthy diets, tobacco use and
increasing lifestyle expectancy”(2019)
 SYNTHESIS AND ACTION OF INSULIN

•
 TERMS
• INSULIN RESISTANCE: condition in which a “normal”
insulin concentration in the blood produces a less
than normal biological response. The body needs
more insulin to transport a given amount of glucose
across the cell membrane into the cell.(2)
• INSULIN SENSITIVITY: It provides an index of the
effectiveness of a given insulin concentration in the
blood. As insulin sensitivity increases, insulin
resistance decreases.(2)
TYPES(based on etiologic origin)
TYPE 1 DIABETES MILLETUS (T1DM)

TYPE 2 DIABETES MILLETUS (T2DM)

GESTATIONAL DIABETES

OTHERS SPECIFIC ORIGINS

 PATHOGENESIS OF TYPE 1A DM
GENETIC FACTORS
• Susceptibilty gene on HLA region in
chromosome 6

ENVIRONMENTAL
FACTORS
• Viral infections
AUTOIMMUNE FACTORS
• Experimental induction
• Islet cell antibodies
• Geographic and
• Insulitis
seasonal variations • Other autoimune diseases

IDIOPATHIC

TYPE 1A DM
 PATHOGENESIS OF TYPE 2 DM
GENETIC AND HERIDITARY FACTORS
INSULIN RESISTANCE
• No definite and consistent gene has
• Lack of responsiveness of the peripheral
been identified
tissues to insulin(skeletal ms and liver)

IMPAIRED INSULIN SECRETION

INCREASED HEPATIC GLUCOSE SYNTHESIS
• Failure of beta cells to secrete
adequate insulin

CONSTITUTIONAL FACTORS
• Obesity
TYPE 2 DM
• Hypertension
• Level of physical activity
 DIAGNOSIS
NORMAL PRE DIABETES DM
HbA1C<5.7% HbA1C: 5.7-6.4% HbA1C>/=6.5%

FPG<100 mg/dL FPG: 100-125mg/dL FPG: >/=126mg/dL

(5.6 mmol/L) (5.6 -6.9mmol/L) (7mmol/L)

2-h PG<140mg/dL IGT: 2-h PG: 140-199 2-h PG>/=200mg/dL

(7.8mmol/L) mg/dL (11.1 mmol/L)
during an OGTT (7.8-11 mmol/L) during an OGTT
during an OGTT
In a patient with
classic symptoms of
hyperglycemia or
hyperglycemic crisis, a
random
PG>/=200mg/dL(11.1
mmol/L)
 TERMS
• FPG (FASTING PLASMA GLUCOSE): requires at
least 8 hours of fasting.
• HbA1C is glycolated haemoglobin.
• IFG (IMPAIRED FASTING GLUCOSE)
• IGT (IMPAIRED GLUCOSE TOLERANCE)
• OGTT (ORAL GLUCOSE TOLERANCE TEST)
MANAGEMENT
 MANAGEMENT
• Fundamental goal of the treatment is to
achieve glycemic control using
 DIET
 EXERCISE
 MEDICATIONS such as INSULIN or oral
hypoglycemic agents
BENEFITS OF REGULAR PHYSICAL ACTIVITY

• Improved blood glucose tolerance

• Increased insulin sensitivity
• Decreased HbA1C
• Improvements in CVD risk factors
• Prevents or delays the transition from pre
diabetes to T2DM
• Moderate intensity ex(150 min/ week) is
associated with reduced mortality and morbidity.
 EXERCISE TESTING
• Light to moderate intensity, for individuals
with DM, pre diabetes and asymptomatic for
CVD : not neccessary

• Individuals with DM, sedentary lifestyle,

vigorous intensity : ECG stress test
• Positive or non-specific ECG changes in
response to exercise are noted or non specific
ST and T wave changes at rest are observed,
follow up diagnostic testing may be
performed.
• Silent ischemia in patients with DM often goes
undetected; therefore annual tetsing of CVD
risk factors should be conducted.
 EXERCISE IN T1DM
• The advantages of exercise in type 1 diabetes
relate more to its protective cardiovascular
effects than to improved glycemic control.
• Exercise is not a tool for improving blood
glucose control in type 1 diabetes, i.e. greater
Insulin sensitivity does not have impact on
pancreatic function.
• Regular exercise lowers the requirements of
exogenous insulin.
POTENTIAL BENEFITS OF REGULAR PHYSICAL ACTIVITY IN T2DM

• Lowers blood glucose during and after exercise

• Increases insulin sensitivity
• Lowers basal and post prandial insulin levels
• Lowers glycated haemoglobin over long term
• Quantitative and qualitative changes in circulating lipids
 lower triglyceride, lower LDL cholesterol, higher HDL
cholesterol
• Improves fibrinolysis, lowers plasma
fibrinogen.
• Lowers systolic and diastolic blood pressures
• Other benefits
• cardiovascular conditioning
• improves strength
• improves sense of well-being (physical and
psychological)
 MECHANISM
• Insulin accelerates blood glucose extraction by
insulin- sensititive peripheral tissues.

• Insulin is associated with increase in insulin

regulatable glucose transporters, GLUT4 and
enzymes responsible for the phosphorylation,
storage and oxidation of glucose.
• With exercise training there is an increase in
conversion of fast twitch glycolytic IIb fibres
too fast twitch oxidative IIa fibres and also
increase in capillary density.
• IIa fibres have more capillary density and are
more insulin sensitivity and responsive than
IIb fibres.
• Exercise training also improves control over
hepatic glucose production by increasing
control of insulin over blood FFAs.
 EXERCISE PRESCRIPTION
AEROBIC RESISTANCE FLEXIBILITY
EXERCISE TRAINING
FREQUENCY 3-7 DAYS/WEEK MINIMUM OF 2
NONCONSECUTIVE
>/= 2-3 DAYS/ WEEK

DAYS/ WEEK
REFERABLY 3
INTENSITY MODERATE
40-59% VO2R or
MODERATE
50-69% of 1RM
STRETCH TO THE
POINT OF
11-12 RPE to TIGHTNESS OR
to VIGOROUS SLIGHT
VIGOROUS 70-85% of 1RM DISCOMFORT
60-80% VO2R or
14-17 RPE
 AEROBIC RESISTANCE FLEXIBILITY
EXERCISE TRAINING
TIME T1DM
150min/week
AT LEAST 8-10 EX
WITH 1-3 SETS OF
HOLD STATIC
STRETCH FOR 10-30
AT MODERATE INTENSITY 10-15 REPS TO SECS; 2-4 REPS OF
Or NEAR FATIGUE PER EACH EXERCISE.
75min/week SET EARLY IN
AT VIGOROUS INTENSITY OR TRAINING.
COMBINATION GRADUALLY
T2DM PROGRESS TO
150min/week HEAVIER WEIGHTS
AT MODERATE TO VIGOROUS USING 1-3 SETS OF
INTENSITY 8-10 REPS.

TYPE PROLONGED, RHYTHMIC

ACTIVITIES USING LARGE
RESISTANCE
MACHINES AND
STATIC, DYNAMIC
AND/OR PNF
MIUSCLE GROUPS FREE WEIGHTS STRETCHING
(WALKING, CYCLING,
SWIMMING)
• A recent systemic review and meta analysis
found no evidence that resistance training is
differs from aerobic exercises in impact on
CVD risk markers or safety of the individuals
with T2DM.
• Flexibility training is not a substitute for other
recommended forms of exercise as it has no
effects on glucose control, body composition
and insulin action.
 PATIENT EDUCATION
• The main problem in promoting physical activity
to people with newly diagnosed type 2 diabetes
is their long-standing sedentary lifestyle.
• Education regarding the benefits of physical
activity should become a vital part in the
management of type 2 diabetes.
• To do this at the time of initial diagnosis may be
useful as the motivation for a behaviour change
is at its highest.
• Make sure the interventions are matched to the
patient’s state of mind.
• Encouragement may take the form of providing
information, recounting difficulties encountered
by others, or lending a sympathetic ear to
problems which the patient may be having.
• Even the most committed individuals who
exercise on a regular basis need some
recognition and support from time to time.
 EXERCISES
AEROBIC EXERCISES: RESISTANCE TRAINING
• Heel raises • Dumbbells
• Jogging • Body weight
• Spot marching • Functional training
• Jumping jacks • Weight cuffs
• Therabands
• Vestibular ball
 EXERCISE TRAINING CONSIDERATIONS
• Co morbid factors ( CVD, Obesity) should be
taken into consideration.
• Interspersing very short, high intensity intervals
during moderate intensity exercise may be
useful to lessen the decline in blood glucose
during early post exercise recovery period.
• Greater emphasis on vigorous intensity exercises
if cardio-respiratory fitness is the aim. (HIIT and
continuous training)
• For T2DM do not allow more than 2
consecutive days without aerobic exercises to
prevent a period of excessive decline in insulin
action.
• Resistance training should be encouraged in
absence of contraindications. Higher
resistance may be beneficial for skeletal
muscle strength, insulin action and blood
glucose control, although moderate resistance
provides equal benefits in sedentary
individuals.
• Appropriate progression of resistance training
is essential to prevent injuries.
(resistance number of sets
frequency)
• With combined training, resistance training
prior to aerobic training may lower the risk of
hypoglycemia in T1DM.
• Foot care advice should be given
• Site and time of insulin injections should be
considered prior to the treatment.
• Extreme temperatures should be avoided.
• Food intake and timing should be noted.
SPECIAL CONSIDERATIONS
or
COMPLICATIONS
 HYPOGLYCEMIA
• Blood glucose levels less than 70mg/dL
• It is a relative contraindication to start an
acute bout of exercise.
• Common adrenergic symptoms associated are
shakiness, weakness, abnormal sweating,
nervousness, anxiety, tingling of mouth and
fingers and hunger.
• Severe neuroglycopenic symptoms include
headache, visual disturbances, mental
dullness, confusion, amnesia, seizures and
coma.
• Sulfonylurea drugs and other compounds that
enhance insulin secretion probably do increase
the risk for hypoglycemia because the effects
of insulin and muscle contraction on blood
glucose uptake are additive.
• Prior to planned exercise, rapid-or short acting
insulin doses will likely have to be reduced to
prevent hypoglycemia, particularly if exercise
occurs during peak insulin times(usually within
2-3 hours)
• Synthetic, Rapid acting insulin analogs induce
more rapid decreases in blood glucose than
regular human insulin.
• Longer acting basal insulin are less likely to
cause exercise induced hypoglycemia,
although dose reduction is advised.
• Blood glucose monitoring , occassionally during
and after exercise is needed.
• Hypoglycaemia may happen during exercise, or
up to 12–14 h or even longer after the end of
the effort.
• Most insulin users will need to consume
carbohydrates before exercise(up to 15 gm)
when starting blood glucose levels are less than
100mg/dL.
• For individuals with Type 1 DM using insulin
pumps, insulin delivery during exercise can be
markedly reduced or the pump can be
disconnected depending on the intensity and
duration of exercise. Reducing basal delivery
rates for up to 12 h postexercise may be
necessary to avoid hypoglycemia.
• Exercise with a partner or under supervision
to reduce the risk of problems associated with
hypoglycemic events.
• The timing of exercise should be considered in
individuals taking insulin or hypoglycemic
agents. For individuals with diabetes using
insulin, changing insulin timing, reducing
insulin dose, and/or increasing carbohydrate
consumption are effective strategies to
prevent hypoglycemia both during and after
exercise.
• Physical activity makes the recognition of
hypoglycaemia difficult because sweating and
tachycardia due to physical effort can mask
similar signs warning of impending
hypoglycaemic effort.
• In older individuals, hypogycemic
unawareness and deteriorated cognitive
function is a critical factor to be considered.
• When hypoglycaemia happens during exercise despite
all efforts to avoid it, it is often extremely difficult to
treat.
• The activity has to be temporarily suspended, and the
amount of carbohydrate required to correct the blood
glucose may be unusually high, often 30–40 g or more.
• Exercise-onset hypoglycaemia tends to be recurrent
and more carbohydrate may be needed within half an
hour (preferably after a repeat blood glucose test).
 HYPERGLYCEMIA
• Blood glucose levels greater than 300mg/dL
• Common symptoms include
 Fatigue
 Increased thirst
 Polyuria
 Weakness
 Acetone breath
 PRE-EXERCISE HYPERGLYCEMIA AND KETONES

• It is consequence of a severe deficit in circulating

insulin, leading to an increase in hepatic glucose
production, a decrease in glucose disposal by muscle,
and the production of ketones.

• Exercise(vigorous intensity) stimulates the secretion

of counter-regulatory hormones (glucagon,
catecholamines, growth hormone and cortisol), all of
which contribute to hyperglycaemia and metabolic
deterioration.
• Hyperglycaemia (>14.0 mmol l1) with ketonuria is an
absolute contraindication to exercise.

• The metabolic imbalance must be corrected by short-acting

insulin injections and the activity must not be resumed until
the blood glucose level starts to decrease and urine ketones
disappear.

• It is recommended that individuals with T1DM check for

urine ketones when blood glucose levels are greater than
250mg/dL before starting exercise.
 HYPERGLYCEMIA without ketones

• It may be the consequence of a mild and relative insulin

deficiency.
• It can be the result of an excess of carbohydrate at the last
meal or snack or the consequence of stress.
• Exercise(upto moderate intensity) is allowed but with caution.
• Good hydration must be stressed (drink before, during and
after exercise).
• A blood glucose measurement is recommended after 30 min
of exercise.
• If no decrease is observed, exercise cessation is recommended
and a correction insulin injection as well.
 DEHYDRATION
• Dehydration resulting from polyuria, a
common occurrence of hyperglycemia, may
contribute to a compromised
thermoregulatory response.
• Thus, a patient with hyperglycemia should be
treated as having an elevated risk for heat
illness requiring more frequent monitoring of
signs and symptoms and additional
precautions must be taken.
 RETINOPATHY
• Individuals with DM and retinopathy are at risk
for retinal detachment and vitreous
hemorrhage associated with vigorous intensity
exercise.
• Risk may be minimized by avoiding activities
that elevate BP.
• Vigorous intensity aerobic and resistance
exercises, jumping, head-down activities and
valsalva maneuver should be avoided.
 AUTONOMIC NEUROPATHY
• Autonomic neuropathy may cause chronotropic
incompetence (i.e., a blunted BP response),
attenuated V˙O2 kinetics, and anhydrosis.
• In these situations, the following should be
considered:
• Monitor the signs and symptoms of silent
ischemia such as unusual shortness of breath or
back pain because of the inability to perceive
angina.
• Monitor BP before and after exercise to
manage hypotension and hypertension
associated with vigorous intensity exercise
• The HR and BP responses to exercise may be
blunted. RPE should also be used to assess
exercise intensity.
 PERIPHERAL NEUROPATHY
• Proper care of the feet to prevent foot ulcers
and lower the risk of amputation.
• Special precautions should be taken to
prevent blisters on the feet.
• Feet should be kept dry and the use of silica
gel or air midsoles as well as polyester or
blend socks should be used.
• Closely examine the feet daily.
 NEPHROPATHY
• There is no evidence vigorous intensity
exercise accelerates the rate of progression of
kidney disease.
• Both aerobic and resistance training improve
physical function and quality of life in
individuals with kidney disease, and should be
encouraged to be active.
 PRE DIABETES
• Characterized by : Elevated blood glucose in
response to dietary carbohydrate , termed as
IMPAIRED GLUCOSE TOLERANCE(IGT) and/or
elevated blood glucose in fasting state, termed as
IMPAIRED FASTING GLUCOSE(IFG).
• These individuals are at very high risk for diabetes
as the capacity of beta cells to hypersecrete insulin
diminishes over time and becomes insufficient to
restrain elevations in blood glucose
 METABOLIC SYNDROME
• It includes hyperglycemia (or current blood
glucose medication use), elevated BP (or
current hypertension medication use),
dyslipidemia (or current lipid-lowering
medication use), and national or regional
cutpoints for central adiposity based on waist
circumference; however, differences in specific
value within these criteria remain.
• Individual can be characterized to have
metabolic syndrome when they display at
least three of the defining risk factors.
 MANAGEMENT
The treatment guidelines
1. National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP
III) focus on three interventions
• weight control
• Physcial activity
• Treatment of the associated CVD risk factors that may include pharmacotherapy

2. The International Diabetes Federation (IDF)

• Moderate restriction in energy intake (EI) to achieve a 5%–10% weight loss
within 1 yr,
• Moderate increases in PA
• Change in dietary intake composition consistent with modifying specified CVD
risk factors.
 CONSIDERATIONS
• Attention should be given to each risk
factor/condition present, with the most
conservative criteria used to set initial
workloads.
• initial exercise training should be performed at
a moderate intensity (i.e., 40%–59% O2R or
HRR) totaling a minimum of 150 min/week or
30 min · d−1 most days of the week to allow
for optimal health/fitness improvements.
• Reduction of body weight is an important goal
for individuals.
• Daily and weekly amounts of PA may be
accumulated in multiple shorter bouts (≥10
min in duration) and can include various forms
of moderate intensity lifestyle PAs. For some
individuals, progression to 60–90 min/day of
PA may be necessary to promote or maintain
weight loss.
• Resistance training, when combined with
aerobic training, can produce greater
decreases in prevalence than that of aerobic
training alone.
• Reported participation in ≥2 d/week of muscle
strengthening activity reduces the risk of
acquiring dyslipidemia, IFG, prehypertension,
and increased waist circumference.
 RECENT ADVANCES
• Work by O’Dea with Australian aborigines
showed that lifestyle modifications with
changes in physical activity and diet can cause
significant weight loss and probably improve
the various components of the metabolic
syndrome.
• A study by Wing et al.36 confirmed the
possible contribution to the benefits of
exercise alone or when exercise is combined
with diet. The diet and exercise group on
average lost twice the amount of weight over
an initial 20 week period, but were also able
to maintain this difference at 60 weeks
compared with those randomized to diet
alone.
 Physical Activity/Exercise and
Diabetes: A Position Statement of
the American Diabetes Association

Aerobic Exercise Benefits

• Aerobic training increases mitochondrial
density, insulin sensitivity, oxidative enzymes,
compliance and reactivity of blood vessels,
lung function, immune function, and cardiac
output.
• In T1DM aerobic training increases
cardiorespiratory fitness, decreases insulin
resistance, and improves lipid levels and
endothelial function
• In T2DM , regular training reduces HbA1C,
triglycerides, blood pressure, and insulin
resistance.
 Resistance Exercise Benefits
• The health benefits include improvements in
muscle mass, body composition, strength,
physical function, mental health, bone mineral
density, insulin sensitivity, blood pressure,
lipid profiles, and cardiovascular health.
 Flexibility and balance exercises
• Limited joint mobility is frequently present,
resulting in part from the formation of
advanced glycation end products, which
accumulate during normal aging and are
accelerated by hyperglycemia
• Stretching increases ROM but does not affect
glycemic control.
• Balance training can reduce falls risk by
improving balance and gait, even when
peripheral neuropathy is present.
• Yoga may promote improvement in glycemic
control, lipid levels, and body composition in
adults with type 2 diabetes.

• Tai chi training may improve glycemic control,

balance, neuropathic symptoms, and some
dimensions of quality of life in adults with
diabetes and neuropathy.
• The benefits of Yoga Practice compared to
Physical Exercise in the Management of Type
2 Diabetes Mellitus: a Systematic Review and
Meta-Analysis by Ranil Jayawardena et al
concluded yoga has beneficial effects on
glycaemic control. However, individual studies
showed considerable heterogeneity, especially
with regards to the lack of uniformity in
physical exercise regimes..
• Recent RCTs suggests that yoga can reduce perceived
stress, improve mood, lower catecholamine and
cortisol levels, whilst also reducing blood pressure,
and other parameters of sympathetic activation in
healthy adults, as well as in patients with diabetes.
• Yogic practices may also have beneficial effects due
to the shifting of the autonomic nervous system
balance from primarily sympathetic to
parasympathetic, by directly enhancing
parasympathetic output.
• These beneficial neuroendocrine and hemodynamic
changes might result in positive changes in related
downstream metabolic parameters.
• In the study Physical activity for diabetes-
related depression: A systematic review and
metaanalysis by Zui Narita et al the result was
derived from an analysis that included 13 RCTs
with 962 participants that had both type 1 and
type 2 diabetes.
• It showed that there was a significant
beneficial effect of physical activity on
diabetes-related depression.
• A low level of brain-derived neurotrophic factor
(BDNF) in the hippocampus and prefrontal cortex
has been shown to play an important role in the
pathophysiology of depression (Yu and Chen,
2011).
• In addition, a previous study verified that physical
activity was correlated with increased levels of
BDNF mRNA, which suggests that it might
possibly have an effect on depressive symptoms.
 REFERENCES
1. ACSM’s guidelines for exercise tsting and
prescription(10th edition)
2. Exercise and Sport in Diabetes(Second
Edition) by DINESH NAGI.
3. Physiology of sports and exercise by Jack H.
Wilmore(5th edition)
4. API Textbook of Medicine
5. Recent advacnces from reference articles.
THANK YOU!