Module 202.3 en_0

Notas do Editor

1. The terms “exercise” and “physical activity’’ will both be used in this module – they are to be taken as meaning the same thing.
2. Note to the educator: Ask participants to list the health benefits of regular exercise. Split the participants into small groups and ask them to discuss these questions, then give feedback to the whole group.
3. Physical activity has benefits for all people with or without diabetes.
4. Larson, E.B. Wang, L., Bowen, J.D. et al. (2006) Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Annals of Internal Medicine, 144(2),73-81.
5. Several recently reported trials show that type 2 diabetes can be prevented and delayed, at least in the short term. The Da Qing study in China followed people for 6 years. Subjects were randomised to three groups: Diet intervention Exercise intervention Combined diet and exercise After 6 years, the “diet’’ group showed a risk reduction of 31%. The “exercise’’ group showed a greater risk reduction (46%). There was no additive effect of diet and exercise, with the “diet and exercise’’ group showing a similar risk reduction (42%) to that of the “exercise’’ group alone. In the Finnish study, 522 subjects with impaired glucose tolerance (IGT) were randomised to a control group or a group who had a diet and exercise intervention. They were followed for 3.2 years. There was a 58% reduction in the incidence of type 2 diabetes in the “diet and exercise’’ group. Pan, X., Li, G., Hu, Y., et al. (1997). Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care, 20(4): 537-44. Tuomilehto J, Lindstrom J, Eriksson JG, et al. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med, 344: 1343-50.
6. The Diabetes Prevention Program also studied people with impaired glucose tolerance (IGT). In this study, people were randomised to one of three groups: Placebo Metformin Diet and exercise The incidence of type 2 diabetes in the metformin group was reduced by 31%. By comparison, the incidence of type 2 diabetes in the “diet and exercise’’ group was 58% - a similar risk reduction to that seen in the Finnish study. The Diabetes Prevention Program Research Group. (2002). The Diabetes Prevention Program (DPP). Diabetes Care, 23(12): 2165-71.
7. Exercise combined with diet also helps to modify body composition known to be associated with insulin resistance. The combined results of many studies show the importance of working at the community level to reduce obesity by providing low caloric and fat products while at the same time increasing opportunities for increased physical activity and raising the perceived value of exercise. A number of countries have national initiatives in place. Note to the educator: Refer to your own country’s initiatives and provide examples to support this slide.
8. Types of exercise can be classified into two groups: aerobic and anaerobic. Aerobic exercise uses large muscle groups that require oxygen for sustained periods. For people who are fit this might be going for a run; for people who are not fit it might be walking 100 paces. Resistance (anaerobic) exercise uses large muscles that do not require oxygen for short periods of exercise. Ask the participants to give examples of aerobic and anaerobic activities.
9. Most guidelines recommend exercise (including aerobic and/or resistance training) several times a week. Recommendations about the amount and kind of exercise differ throughout the world. The IDF Global Guideline for Type 2 Diabetes recommend 30-45 minutes a day, 3-5 days a week. Some countries also recommend resistance exercise at least 3 times a week. Resistance training does not necessarily require expensive equipment. Weights used can be as simple as a can of soup or a packet of grain. Progressive resistance training has shown benefits when people progress to three sets of approximately eight resistance type exercises at moderately high intensity (eight repetitions at the maximum weight that can be lifted eight times). In resistance training, it is better to use repetitive light weights than heavy weights. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes, 32(suppl 1). International Diabetes Federation. (2005) Global Guideline for type 2 diabetes. Brussels: IDF
10. Brisk walking is probably the most common form of aerobic exercise.
11. The type, frequency, duration and intensity of exercise should be adjusted according to individual fitness levels. In general, training should be modulated to achieve an energy expenditure of 1000-2000 calories/week and 150-500 calories/session. Each exercise session should include a 5- to 10 minute pre-exercise warm-up and a 5- to 10 minute post-exercise cool down of low-intensity aerobic activity (walking, cycling) and slow, rhythmic, and stretching exercise (calisthenics) to prepare the skeletal muscles, heart and lungs for a progressive increase in exercise intensity and to gradually bring the heart rate down following the activity. Sedentary individuals should start slowly. They can start by increasing daily physical activity (using stairs instead of elevators, for example) plus daily short sessions of between 5 to 10 minutes. Rate of progression: Initial conditioning of 4 to 6 weeks; if a person has not been physically active, it may take them 4 to 6 weeks to become conditioned The improvement phase may last 4 to 5 months; over this time the person gradually builds up the level of activity to their goal time and intensity Maintenance thereafter For the initial exercise prescription in relation with the fitness level, together with the appropriate screening of the person (medical history, physical examination), it is important to determine the exercise habits using a valid and appropriate assessment tool, such as a physical activity questionnaire, to rank individuals from the least to the most active.
12. Discuss the tips to help people start physical activity. While these are recommendations, goals should be individualised and set realistically.
13. Setting realistic goals is important to achieve success. Goals should be specific, measureable, achievable, realistic and timed. Suggest everyday activities to start with; When going shopping, park at the far end of the parking lot Walk instead of going by car Cleaning the house when in a good mood Dancing around the house Walking up one flight of stairs instead of taking the elevator
14. People who have not been recently physically active and are intending to start exercising should see a health care professional in order to identify the their risks associated with exercise and how to manage these risks.
15. As healthcare providers we need to ensure that people who undertake physical activity are aware of safety precautions. They should be reminded to drink adequate water to avoid becoming dehydrated, especially if exercising in a hot climate They should be reminded to check their footwear; feet should be protected from the environment Shoes and socks should keep the feet as dry as possible and not cause reddened areas or blisters People with diabetes who take any kind of blood glucose-lowering medicine should be advised to wear some form of identification; in case of a hypoglycaemic episode while exercising, a bracelet or some identification indicating the person has diabetes might result in faster and more appropriate help being given. If a person has regular exercise partners, they should be made aware of the signs and symptoms of hypoglycaemia and how to treat it
16. If blood glucose is >14mmol/L (252mg/dl), strenuous exercise is not recommended as it may cause the blood glucose to increase. If there is not enough insulin in circulation, the liver will respond to exercise by releasing more glucose. In type 1 diabetes, it may also lead to accelerate fat catabolism and ketone formation. If ketones are present, the person should NOT exercise. To reduce the risk of hypoglycaemia, people on oral agents or insulin should eat before exercising if the blood glucose is <6mmol/L (108mg/dl). More food may be needed during the exercise. Special precautions need to be taken when treating hypoglycaemia would prove difficult; physical activity under water is an example. People at risk of hypoglycaemia should plan very carefully when undertaking activities of this kind. American Diabetes Association. (2008) Medical management for type 1 diabetes. Alexandria VA: ADA. American Diabetes Association. (2008) Medical management for type 2 diabetes. Alexandria VA: ADA.
17. There are risks associated with unplanned physical activity. The primary risk is hypoglycaemia. Therefore, as much as possible, physical activity should be planned for and proactive changes made to insulin dose or carbohydrate intake. People need to monitor their blood glucose frequently after exercising because of the risk of delayed hypoglycaemia. They may also need to decrease insulin or increase their bedtime snack to prevent a hypoglycaemic event overnight.
18. Sometimes people may be surprised by hypoglycaemia. This is because an activity may not have been perceived as physical activity but rather activities of daily living, such as cleaning the house or sexual activity. Hyperglycaemia may occur after brief, very intense exercise due to increased glucose production that exceeds increases in glucose disposal. Blood glucose levels need to be closely monitored before, during and after exercising and insulin doses adjusted accordingly. People should not exercise if ketones are present as exercise will exacerbate fat catabolism and ketone formation. There is also a high risk of severe dehydration.
19. The risk of hypoglycaemia is reduced in type 2 diabetes. However, people on insulin secretagogues or insulin therapy may need to adjust their medication prior to prolonged and excessive exercise and should always carry a source of glucose. People with cardiac history should consult their physician before undertaking an exercise program. Considerations also need to be given to other co-morbidities such as arthritis and diabetic complications.
20. People with peripheral neuropathy should not undertake weight-bearing exercise or any exercise that might abruptly change the blood pressure. They should be advised to undertake non-weight-bearing exercise such as riding a stationary/exercise bike, swimming etc.
21. Exercise that increases blood pressure, and therefore renal perfusion, is contraindicated in people with nephropathy.
22. Caution needs to be taken to avoid a bleed or retinal detachment in people with significant diabetic retinopathy. Following photocoagulation people should be advised to avoid exercising for three weeks. Source: Joslin Am Coll Sports Med