4/24/2018

1

Physical Activity/Exercise Prescription with Diabetes

B R AD H I NTERMEYER C E P A C SM

S A NFORD H E ALTH C A RDIAC R E H AB A N D D I ABE TES E XE RCISE

The adoption and maintenance of physical activity are critical foci for blood glucose management and overall health in individuals with

diabetes and prediabetes.

The challenges related to blood glucose management vary with diabetes type, activity type, and presence of diabetes-

related complications

Physical activity and exercise recommendations, therefore, should be tailored to meet the specific needs of each individual (ITP)

Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association

http://care.diabetesjournals.org/content/diacare/39/11/2065.full.pdf

4/24/2018

2

• 27% and increasing; number of patients entering Cardiac Rehab with a diagnosis of Diabetes

• Exercise is a class I indication in the

management of Diabetes • Our programs have a very favorable

impact on Diabetes management due to our frequent contacts with patients and the ability to facilitate appropriate referrals

Diabetes and CardioPulmonary Rehab

TYPES AND CLASSIFICATIONS REVIEW

•Type 1 - (5%–10% of cases) Immune system destroys beta cells in the pancreas and body is unable to produce insulin

•Type 2 - (90%–95% of cases) progressive increase in body’s ability to produce and utilize insulin

•Prediabetes - blood glucose is above the normal range but not high enough to be classified as diabetes

Criteria for the Diagnosis - ADA 1. A1c of 6.5% or more; or

2. Fasting BG 126 mg/dL or more. (no caloric intake for at least 8 hours); or

3. A 2-hour BG 200 mg/dL or more during an oral glucose tolerance testb; or

4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random BG 200 mg/dL or more

Categories of increased risk for diabetes

1. Impaired fasting glucose, for example, fasting BG between 100 and 125 mg/dL

2. Impaired glucose tolerance, for example, 2-hour oral glucose tolerance test result between 140 and 199 mg/dL

3. Hemoglobin A1c between 5.7% and 6.4%

4/24/2018

3

Resources

Recommendations for Managing Patients With Diabetes Mellitus in Cardiopulmonary Rehabilitation - AN AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION STATEMENT (2012) https://www.iscvpr.org/wp-content/uploads/2014/04/Recommendations_for_Managing_Patients_With_Diabetes1.pdf

Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association (2016) http://care.diabetesjournals.org/content/39/11/2065

Exercice management in type 1 diabètes: a consensus statement 2017 https://media.wix.com/ugd/776db1_eb6d16b8f2bb43028b83e5e0efcddbec.pdf

Diabetes Self-management Assessment

Topics

Medical history

Diagnosis and duration: type 1 diabetes, type 2 diabetes

Hemoglobin A1c or estimated average glucose values

Recent BG values or readings

Presence of comorbid conditions

Neuropathy

Retinopathy

Last examination for vision, dental, and feet

https://www.iscvpr.org/wp-content/uploads/2014/04/Recommendations_for_Managing_Patients_With_Diabetes1.pdf

Diabetes Self-management Assessment

Topics

Nutrition management

Impact of nutrition on BG

Weight loss or gain

Amount desired

Use of food diaries

Prevention of weight regain

Referral to dietitian

History of bariatric surgery

4/24/2018

4

Diabetes Self-management Assessment

Topics

Exercise

Relationship between exercise and BG

Goal ranges for BG pre, during and post activity

Amount and type of activity

Safety precautions

Diabetes Self-management Assessment

Topics

Use of BG monitoring

Type of meter in use at home

Frequency and timing of BG readings

Assess patient knowledge and ability in performing quality control checks with glucose control solution and calibration of glucose monitor if warranted

Record keeping and interpretation of glucose results

Diabetes Self-management Assessment

Topics

Medications

Understanding of medication action and potential for adverse effects with special attention to concomitant medications that affect glycemic control,

Referral to appropriate resources for financial assistance as needed

Specific details of insulin use if prescribed

Delivery device for injection (vial and syringe, insulin pen, pump)

Time of day insulin injected (bedtime, premeal, correction doses) relevant to insulin action pattern and duration

4/24/2018

5

Diabetes Self-management Assessment

Topics

Preventive foot care

Annual foot care/comprehensive examination

Importance of daily foot monitoring

Seek care from a foot specialist for the treatment of foot ulcers and wound care

Coping strategies

Identify barriers for change such as depression, low socioeconomic status and/or illiteracy

Need for adaptive devices such as magnifiers, large-display glucose meters, and insulin pens

Additional social support needed such as referral to mental health professional, support groups, or community agencies

Exercise Prescription

4/24/2018

6

Benefits of Aerobic Exercise/Diabetes Type 1 - increases cardiorespiratory fitness, decreases insulin resistance, improves lipid levels and endothelial function

Type 2 - regular training reduces A1C, triglycerides, blood pressure, and insulin resistance.

Moderate to high volumes of aerobic activity are associated with substantially lower Cardiovascular and overall Mortality Risks in both type 1 and type 2 diabetes

METs - The 5 and 10 Rule

http://circ.ahajournals.org/content/122/8/790

4/24/2018

7

Lift Things Up and Put Things Down

Resistance Training Benefits muscle mass

body composition

strength

physical function

mental health

bone mineral density

insulin sensitivity

glycemic control

cardiovascular health

fat mass

blood pressure

4/24/2018

8

Keep Moving!

All adults, and particularly those with type 2 diabetes, should decrease the amount of time spent in daily sedentary behavior

Prolonged sitting should be interrupted with bouts of light activity every 20-30 min for blood glucose benefits

The above two recommendations are additional to, and not a replacement for, increased structured exercise and incidental movement

2 min bouts of light activity every 20-30mins!

What we already know Everyone needs to be physically active!

How we approach exercise prescription with any population group isn’t really any different.

We need to get heart rates up, add resistive workloads to skeletal muscles, stay flexible, stay balanced and make sure

the intensity/volume/progression is appropriate to each individual

4/24/2018

9

What we need to remember

Individual responses to food, stress, activity, medication, the ability to produce and be sensitive to insulin can vary greatly depending on the person

Taking the time to learn individual patterns helps us strategize ways to keep energy (glucose) regulated to allow our patients the ability to walk, run, dance, lifts weights, play and stay active

When to Test in Cardiac Rehab? First questions –

-Type of Diabetes and History (pre diabetes, newly diagnosed, long term management

-What medications are they currently taking. Insulin or Insulin like meds? Risk of lows?

- Current department policies

- Current recommendations from Provider and Care Team

Once these questions are taking into account we can gain really good information if we test pre and post (and sometimes in during )

exercise

4/24/2018

10

Pre Exercise Hypoglycemia Care

Patients using Insulin like oral meds and or Insulin should maintain BG levels of 100mg/dl or higher during exercise

BG should be taken before exercise

Exercise after eating or consuming 15g or more of carbohydrates

Assess patient level of understanding and discuss signs and symptoms and treatment options

Post Exercise Hypoglycemic care

Check BG with 15 mins post exercise

Be aware of post exercise hypoglycemia risk that can last 24 hours post exercise and encourage patients to continue to check

Try for post exercise Glucose goal of 100mg/dl or higher upon discharge

Consume 15g of easily digestible carb source

Discuss with patient physician if medication adjustments need to be modified before exercise sessions

4/24/2018

11

Hypoglycemia Recommendations Hypoglycemia (BG < 70 mg/dL) requires ingestion of glucose or carbohydrate-containing foods

The 15/15 rule - Give 15 grams of rapidly digested carbs, wait 15 minutes is preferred treatment for the conscious individual with hypoglycemia

If BG 15 minutes after treatment shows continued hypoglycemia, treatment should be repeated

Once BG returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia

added fat prolongs acute hypoglycemic episode

Overtreating low BG can lead to hyperglycemia and weight gain

Pre Exercise Hyperglycemia Care Type 1

Avoid exercise: If fasting BG is 300 mg/dL or higher and/or ketosis is present

A person with type 1 diabetes who is deprived of insulin for 12 to 48 hour can become ketotic

Exercise can aggravate the hyperglycemia and ketosis and vigorous activity is not recommended in the presence of ketosis

It is not necessary to postpone exercise based simply on hyperglycemia if urine, blood ketones, or both are normal

Help patient determine possible causes of increased BG

Check for medication compliance, Insulin pump function, signs or symptoms of an infection or dehydration

If fasting BG or postprandial BG continues to be elevated, consider an adjustment in insulin dosing; refer patient to physician, CDE, or both for further intervention

4/24/2018

12

Pre Exercise Hyperglycemia Care Type 2

Patients should exercise with caution if BG is 300 mg/dL or higher

With repeated BG levels of 300 mg/dL or higher, obtain BG goals from the physician for planning treatment, interventions, or both needed for an exercise session

If fasting BG or postprandial BG continues to be elevated, consider an adjustment in medications; refer patient to physician, CDE,

If elevated BG is caused by timing of meal and patient is asymptomatic, advise exercise with caution; exercise may decrease the BG level

BG can be evaluated during exercise to make sure it is not increasing;

if BG increases, exercise may need to be stopped until patient is within goal range

Medications

4/24/2018

13

Type 1 extras

Don’t hesitate to contact Endocrinologist or CDE to help plan strategies for successful exercise treatments. Adjustments in basal rates or bolus units many need to be modified for particular activities

Different exercises and order will create different blood sugar response – Weights before aerobic activity?

Blood sugar may rise with interval training, higher intensity and weight lifting

Great new tools and position stands just posted specifically for exercise and type 1.

Type 1 Extras

Type 1

4/24/2018

14

Other Challenges with Exercise Prescription

People with diabetes, particularly of long duration, are susceptible to autonomic neuropathy and are less likely to have symptoms, for example, angina while experiencing myocardial ischemia; therefore, exercise training tailored by the recognition of symptoms of myocardial ischemia is not straightforward in these patients; indeed, some patients can have a large area of ischemic myocardium before having any chest discomfort or angina equivalent

Some people with diabetes may have developed long-term complications that make cardiopulmonary rehabilitation more challenging; examples include blindness, nephropathy, peripheral neuropathy with decreased sensation, peripheral vascular disease with significant claudication or digit/limb amputation, and cardiac autonomic neuropathy, characterized by resting tachycardia, inability to increase the heart rate in response to exercise, and orthostatic (postural) hypotension

Key Points

Optimal BG control has been shown to decrease the incidence of microvascular complications

Exercise helps maintain appropriate BG levels and is a class I indication

The cardiopulmonary rehabilitation setting represents an excellent opportunity for health care providers to monitor and manage DM because of the frequent contact and close relationship that develops

Aerobic and Strength training exercise may trigger hypoglycemia in people with diabetes, particularly in those with tight BG control; this provides positive feedback regarding the effects of exercise on glycemic control

Diabetes is a major risk factor for cardiovascular disease; people with diabetes are 2 to 4 times more likely to have cardiovascular disease than people without DM

Thank You!

Brad Hintermeyer Exercise Physiologist Sanford Health

Cardiac Rehab, Medical Fitness and Diabetes Exercise 701-234-2881

bradley.Hintermeyer@sanfordhealth.org