The Role of Exercise in Diabetes Mellitus

Posted by Chester Ryan Azurin on June 12, 2011 Leave a Comment

Clinically Relevant Anatomy and Pathophysiology
Diabetes Mellitus primarily aIIects the Islets oI Langerhans oI the pancreas, where glucagon
(Irom the alpha cells) and insulin (Irom the beta cells) are produced. Glucagon raises the blood
glucose level, while insulin lowers it. In Type 1 DM (Insulin Dependent), the loss oI Iunction oI
the beta cells leads to an absolute insulin deIiciency. In Type 2 DM (Non-insulin Dependent), the
impaired production and secretion oI insulin by the beta cells is concommitant with the impaired
ability oI the tissues to utilize insulin (termed insulin resistance). The resulting accumulation oI
glucose in the blood is Iurther elevated by the greater synthesis oI glucose in the liver, which
releases it to the general circulation.
Prevalence and Incidence
Diabetes Mellitus (both Type 1 and Type 2) is now a global epidemic. Usually correlated with
being overweight and obese, a sedentary liIestyle and Iamilial history are also being considered
as risk Iactors.
According to the research entiltled 'Global Prevalence oI Diabetes by Sarah Wild, MB,
BCHIR, PhD and associates, "the total number of people with diabetes is projected to rise from
171 million in 2 to 3 million in 23. 1he prevalence of diabetes is higher in men than
women, but there are more women with diabetes than men. 1he urban population in
developing countries is projected to double between 2 and 23. 1he most important
demographic change to diabetes prevalence across the world appears to be the increase in the
proportion of people greater than 5 years of age."
Diabetes can be categorized as acquired or hereditary. The lack or decrease in exercise,
elevated stress levels, and unhealthy diet all predispose an individual to Type 2 Diabetes Mellitus
even without a clear Iamily history.
Considered an endocrine disorder, this could also occur in pregnant women during gestational
stage. Susan Y. Chu, PhD, MSPH, and associates, in their research entitled 'Maternal Obesity
and Risk oI Gestational Diabetes Mellitus, concluded that "high maternal weight is associated
with a substantially higher risk of CDM."
In general, Diabetes Mellitus is a chronic disorder characterized by hyperglycemia or
hypoglycemia (or impaired glucose tolerance), with subsequent disruption oI the metabolism oI
carbohydrates, Iats and proteins. Over time, it results in serious small and large vessel vascular
complications and neuropathies.
Clinical Presentation
Classic triad oI Diabetes Mellitus are polydipsia (increased thirst), polyphagia (increased appetite
and ingestion) and polyuria (increased urination caused by osmotic diuresis).
Amidst the increased appetite and craving Ior Iood, persons with DM (usually Type 1) may still
experience weight loss because oI the improper Iat metabolism and breakdown oI Iat stores.
Diabetics are more prone to hypoglycemia than hyperglycemia during exercise. But physical
therapists must be eIIiciently adept in distinguishing the diIIerences oI the signs and symptoms,
including the dangerous Diabetic Ketoacidocis (DKA).
During Diabetic Ketoacidocis (DKA) the patient might experience abdominal pain, anorexia,
nausea, vomitting or diarrhea. This occurs more in children. Patient will have conIusion and dull
mental state which can lead to coma. There is an increase in pulse rate, yet weak. There is an
initial deep and rapid breathing which could lead to Kussmaul respiration. Cardinal sign is a
Iruity or acetone breath. Urine output is increased and the glucose level is extremely high
(greater than 300 mg/dl). Ketones are high and pH is acidotic (less than 7.3). The skin is warm
and dry. Onset is rapid, which is less than 24 hours.
While on hyperglycemia, there are no gastrointestinal symptoms, usually occur in adults with
underlying chronic disease and the patient is also in a dull, conIused mental state. Skin is warm
and dry, pulse and respiratory rate are high, ketone and pH level are normal, relatively high
glucose level and the onset is slow (may take days).
On the other hand, hypoglycemia can occur with all ages. The patient may Ieel hungry with
diIIiculty in concentration and coordination which could eventually lead to coma. Skin is cold
and clammy, there is proIuse sweating, increased pulse rate, shallow respiration, considerably
low glucose level, ketones and pH are normal and the onset is rapid.
Diagnostic Procedures
Fasting glucose level oI greater than 126 mg/dl is considered positive.
The strictest criteria is according to the World Health Organization, which states that the
diagnosis is positive iI ~ venous plasma glucose concentration is greater than 11.1 mmol/L 2
hours after a 75g glucose tolerance test."

utcome Measures
The Iollowing can be used:
O FOTO (Focus On Therapeutic Outcomes) under the Endocrine, Metabolic and Immunity
Disorders oI the Impairment Categories
O Foot and Ankle Ability Index
Management / Interventions
For Type 1 (Insulin Depentdent) Diabetes, intramuscular administration oI insulin is needed.
Dosage is always expressed in USP units. Humalog is the Iastest acting insulin, acting within 15
minutes. The PZI has the longest peak oI 8-20 hours and has the longest total duration oI 36
hours. On the other hand, the Lantus is the only one 'without peak and lasts Ior 24 hours.
For Type 2 (Non-Insulin Dependent) Diabetes, popular oral hypoglycemics include MetIormin
and SulIonylureas. Insulin sensitizers such as Rosiglitazone and Pioglitazone are also prescribed.
Weight management, nutritional and diet counselling combined with physical therapy / exercise
prescription completes the wholistic treatment approach.
Physical Therapy Management
Patient education Ior proper Ioot care is an essential part oI the physical therapy program Ior
diabetic patients. Therapeutic exercises comprise the major aspect oI the management.
Exercise Therapy
A sound, individually tailored exercise prescription is a cornerstone in the management oI
Diabetes Mellitus.
The goal is to address the beyond normal BMI score (25 and above) Ior overweight and obese
patients. Numerous studies show that a regular exercise program Ior diabetics has a proIound
eIIect on the regulation oI their blood glucose levels.
From the archives oI the Journal oI the American Medical Association (JAMA), a
research conducted by Daniel Umpierre, MSc and associates entitled 'Physical Activity Advice
Only or Structured Exercise Training and Association With HbA1C Levels in Type 2 Diabetes,
A Systematic Review and Meta-analysis, it was concluded that "structured exercise training
that consists of aerobic exercise, resistance training, or both combined is associated with
HbA1C reduction in patients with 1ype 2 diabetes. Structured exercise training of more than
15 minutes per week is associated with greater HbA1C declines than that of 15 minutes or
less per week. Physical activity advice is associated with lower HbA1C, but only when
combined with dietary advice."
Similarly, a randomized controlled trial by Timothy S. Church, MD, MPH, PhD and associates
which was entitled 'EIIects oI Aerobic and Resistance Training on Hemoglobin A1C Levels in
Patients With Type 2 Diabetes made a conclusion that "among patients with 1ype 2 Diabetes
Mellitus, a combination of aerobic and resistance training compared with the nonexercise
control group improved HbA1C levels. 1his was not achieved by aerobic or resistance training
alone."
Guidelines Ior a sound exercise program are as Iollows:
O Do not exercise iI the blood glucose level is less than 100 mg/dl or greater than 250
mg/dl.
O PreIerably, exercise indoor instead oI outdoor to minimize the risk oI integumentary and
musculoskeletal trauma, as well as Ior the patient to have an immediate access to
necessary things to address hypoglycemia, hyperglycemia or diabetic ketoacidocis.
O Patients are highly advised to wear the medical tag Ior diabetics each time they come out
oI their house to go somewhere else.
O Always have a carbohydrate snack at hand every exercise session. A glass oI orange juice
or milk is a good pickup Ior a patient who is experiencing hypoglycemia.
O Exercise in a comIortable temperature. Never exercise in extreme temperatures.
O For Type 1 (Insulin Dependent) patients, never exercise during the peak times oI insulin.
Collaborate with the nurse in charge Ior the patient regarding the type oI insulin
administered.
O Type 2 diabetics are advised to have an average oI 30 minutes oI exercise duration per
session.
O Always wear proper Iootwear and exercise in a saIe environment.
O Type 1 diabetics may need to reduce insulin or increase Iood intake prior to the start oI an
exercise program. The physical therapist must coordinate with the reIerring physician in
this case.
O During prolonged exercise duration, a 10-15 grams oI carbohydrate snack is
recommended Ior every 30 minutes.
O Clients who are on SulIonylureas are red Ilags because it can cause an exercise-induced
hypoglycemia. Closely coordinate with the reIerring physician iI this was missed prior to
reIerral.
O Menstruating women need to increase insulin during menses, especially iI they`re
not active.
O There should be no short-acting insulin injections close to the muscles to be exercised
within one hour oI exercise.
O Patients should eat 2 hours beIore exercising. II planning to exercise aIter meal, patients
must wait 1 hour prior to start.
O Patients must always carry their own portable blood glucose monitor. They must check
their glucose levels beIore and aIter exercise.
O Patients are advised to drink 17 oz. oI Iluid beIore exercise.
O II blood glucose is less than 100 mg/dl but not less than 70mg/dl, the physical therapist
may provide carbohydrate snack and then recheck the glucose level aIter 15 minutes.
O Make sure that the type oI exercise doesn`t contribute an unnecessary stress to the
patient. Stress increases insulin requirements. A gradual progression Irom aerobic and
resistance exercises is the key.
O Avoid exercising late at night.
O II Iaced with an unexpected and diIIicult situation wherein the physical therapist is in
doubt whether the patient is experiencing hyperglycemia or hypoglycemia, always give a
glass oI orange juice or milk, or a carbohydrate snack. This is the saIest action because
this can relieve hypoglycemia (iI it is indeed) and cannot harm iI it is hyperglycemia.
O Exercise Iive times a week as a maintenance (or at least every other day) and at the same
schedule / time, preIerably.
O As much as possible, patient must not exercise alone, so that there will always be
someone to help in unexpected situations.
O Good examples oI carbohydrate snacks (10-15 grams oI carbohydrates) are halI a cup oI
Iruit juice or cola, 8 oz. oI milk, 2 packets oI sugar, 2 oz. tube oI honey or cake deco gel.
Differential Diagnosis
The physical therapist must screen Ior the Iollowing:
O Complex Regional Pain Syndrome
O Carpal Tunnel Syndrome
O Dupuytren`s Disease
O Flexor Tenosynovitis
O Adhesive Capsulitis
Key Evidences
O 'Physical Activity Advice Only or Structured Exercise Training and Association With
HbA1C Levels in Type 2 Diabetes, A Systematic Review and Meta-analysis by Daniel
Umpierre, MSc and associates.
O 'EIIects oI Aerobic and Resistance Training on Hemoglobin A1C Levels in Patients With
Type 2 Diabetes by Timothy S. Church, MD, MPH, PhD and associates.
References
1. Sarah Wild,Gojka Roglic, Anders Green, Richard Sicree, and Hilary King. Global Prevalence
oI Diabetes: Estimates Ior the year 2000 and projections Ior 2030. Diabetes Care May 2004 vol.
27 no. 5 1047-1053
2. Susan Y. Chu, William M. Callaghan, Shin Y. Kim, Christopher H. Schmid, Joseph Lau,
Lucinda J. England,Patricia M. Dietz. Maternal Obesity and Risk oI Gestational Diabetes
Mellitus. Diabetes Care August 2007 vol. 30 no. 8 2070-2076
3. Daniel Umpierre, Paula A. B. Ribeiro, Caroline K. Kramer, Cristiane B. Leito, Alessandra
T. N. Zucatti,Mirela J. Azevedo, Jorge L. Gross, Jorge P. Ribeiro, Beatriz D. Schaan. Physical
Activity Advice Only or Structured Exercise Training and Association With HbA1c Levels in
Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA. 2011;305(17):1790-1799.
4. Timothy S. Church, Steven N. Blair, Shannon Cocreham, Neil Johannsen,William Johnson,
Kimberly Kramer, Catherine R. Mikus,Valerie Myers, Melissa Nauta, Ruben Q. Rodarte, Lauren
Sparks, Angela Thompson,Conrad P. Earnest. EIIects oI Aerobic and Resistance Training on
Hemoglobin A1c Levels in Patients With Type 2 Diabetes: A Randomized Controlled
Trial.JAMA. 2010;304(20):2253-2262.