Jurnal Diabetes
Jurnal Diabetes
8, 2008 pp:1-15
Review Article
3-Academic Faculty of Department of Internal Medicine, East Tennessee State University, USA
Abstract
Sedentary life style is considered as a main risk factor for DM-II. The role of regular exercise
is appreciated in both primary prevention and treatment. Diabetic people can benefit from
physical activity in order to have a better control on blood glucose level, lipid profile, body
weight, and blood pressure. Furthermore, psychological improvements may follow such as
decreasing anxiety or depression and improvement of sleep quality.
Different kinds of training including aerobic, resistive, and flexibility exercises could be
recommended, but some parameters like intensity, duration, and frequency of exercises as well
as safety measures should be explained to the patient when prescribing an exercise program.
A thorough medical evaluation is required before starting an unaccustomed exercise program
in order to modify it, as needed.
It is recommended that diabetic people participate in moderate aerobic (40-60% Vo2max) and
resistive (30-50% 1RM) exercises 3-5 and 2-3 sessions per week, respectively. However, it is
a general recommendation, and an expert in exercise therapy should tailor the program with
respect to individual conditions.
Corresponding Author: the Opposite Side of Shari'ati Hospital, Jalal-al-Ahmad St. Tehran, Iran, Tel: + 98 21
88630227, Fax: + 98 21 88003539. E-mail: [email protected]
2 Hassabi et al.: Exercise Prescription in
heavy weight lifting are some examples of more precisely, it is advised to first measure
anaerobic activities. These exercises are the hearts chronotropic reserve (Max HR
generally used to increase ones speed and Resting HR). Then multiply the min by
strength. max intended percentage of heart rate in
this chronotropic reserve and finally add
-Resistive exercises: This term is usually this minimum and maximum rates to the
given to activities done against a resistance. resting heart rate to determine the intended
The resistance here may be the body weight range of HR with the prescribed
or elastic force or external weights. The routine[1,6].
main goal of these activities is to increase The rating of perceived exertion is used as
ones strength and endurance [1]. One must an estimate of the exercise intensity. RPE
keep in mind that, with quitting these offers a numeric measure for different
routines for a long time, the improvements levels of activity, ranging from minimum to
may be lost. Thus adherence to regular maximum exertion. Point scales like the
exercise routines is strongly recommended. BORG scale, rate the exercise intensity
-Flexibility exercises: These trainings are from minimum (equal to Borg scale of 6) to
intended to increase the overall flexibility maximum (Borg scale of 20). Studies have
of body and to improve the range of motion shown that RPE correlates well with the
of joints. It is important to point out the VO2 Max and HR and this method is
correct way of performing, duration, considered as an invaluable tool in exercise
number of repetitions and frequency of prescribing [6,7].
stretching movements while prescribing Repetition maximum (RM) is usually used
them [1]. to determine the intensity of resistive
Frequency: Frequency refers to the number exercises. RM is defined as the maximum
of sessions practiced weekly. The weight or load that muscle can bear in a
recommended frequency is usually 3 to 5 given range of motion with a given
sessions weekly. If adhering to the 3 days a repetition. 1RM applies to the maximum
week frequency protocol, one may space weight that muscle can overcome no more
practice sessions to every other day, so that than once. Thus, nRM applies to the
the overall exertion be distributed more maximum load that muscle can overcome, n
evenly throughout the week [6, 7]. times and not more. Usually a percentage of
Intensity: One could monitor the intensity the RM is used to determine the amount of
of aerobic exercises via different methods. load or resistance used in resistive exertions
VO2 Max, Target heart rate and RPE are [1, 7].
some of these measures [6].
Given the costs and the needed The role of physical activity in
infrastructure for directly measuring the VO2 diabetics
Max, in real world, exercise sessions are
prescribed and monitored via easier and Diet, prescription anti hyperglycemic drugs
more available methods [1]. and exercise routines are all important
Heart rate is directly proportional to the contributors to treatment of diabetes.
intensity of exertion and the VO2 Max. Physical activity and sports are one of the
Accordingly, often the intensity of exercise main contributors to both prevention and
is determined based on the maximal management of diabetes.
predicted heart rate (Max HR= 220 - Age). Prevention: Metabolism abnormalities
The intensity of exercise should be adjusted leading to insulin resistance are usually
as to maintain the HR within a given range reversed by weight loss, dieting and
during exertion, for example, 60-80% of increase in physical activity. Exercise may
Max HR. In order to measure this range increase bodys response to intrinsic
insulin, by multiple mechanisms including
4 Hassabi et al.: Exercise Prescription in
Age>35 yrs
Age> 25 yrs (if more than 10 yrs DMII or more than 15 yrs DMI)
Any Other Cardiovascular Risk Factor Such As High BP, Smoking , Disordered Lipid Profile,
Sedentary Life Style, etc.
Microvascular Diseases (Proliferative Retinopathy or Microalbuminuria)
Peripheral Vascular Disease
Autonomic Neuropathy
6 Hassabi et al.: Exercise Prescription in
Relative Intensity
complications of diabetes, may have one must use drills that involve all groups
difficulty with even 20-30 minutes of of large muscles. By definition, the ideal
walking. Perhaps, for this group of number of repetitions for each move is 10-
patients, one may use a host of other 15 times against a moderate resistance
physical activities which have same (about 30-50% of 1RM) [12, 23]. Once the
metabolic effects as aerobic exercise [23]. person becomes capable of completing 15
repetitions against a given resistance, then
Resistive exercises have been suggested one could gradually add to the resistance
recently, as a safe and effective therapeutic [12]. Studies have shown that by using
tool in treatment of many chronic diseases higher resistance, the lowering effect on
like diabetes. As per available data, these the HgbA1c becomes even more prominent.
types of trainings, same as aerobic routines, Thus, for patients with good physical
are very effective in improving insulin condition, the physician may prescribe
sensitivity [21, 23, 24], increasing daily heavier resistance and subsequently less
caloric consumption and improving ones repetitions (like reps of 8-10 times) [18,
quality of life [23,25,26]. Other than the 23]. Perhaps, exercise using resistance
aforementioned benefits, resistance training machine is preferred over using free
potentially improve muscular strength, weights, given that it's easier and safer
increase body fat-free mass, improve bone [12].
mineral density and decrease symptoms
and signs of arthritic diseases, all of which There is some data suggesting that using a
result in rapid improvement of patient's combination of aerobic and anaerobic
functional capacity. Patients usually find exercises may have a synergistic effect [8,
this as an early reward for their hustle 28]. Recently following a randomized
which in turn leads to improvement of their clinical trial involving 251 adults,
self-confidence [12, 18, 23]. Given that researchers demonstrated that combining
daily resistive exercises usually consist of aerobic with resistive exercises improves
various activities, some patients find them patients serum levels of HgbA1c more
more exciting and easier to adhere to [18]. prominently than using each exercise
modality alone [29]. However, these
A clinical study on the effect of resistance studies do have some limitations that
training in improving the serum levels of warrant further research to shed some light
HbA1c in type II diabetics suggests that on the correct answer [23].
performing these routines in a gym or
recreational centers has higher success Flexibility or stretching exercises, are often
compared with performing the same recommended to increase the joints range
exercises in ones home [27]. of motion and decrease potential of injuries
Its prudent to realize that resistive exercise like muscle strain. Though some of
routines, as opposed to simple aerobic previous studies found that these trainings
exertions, may require machines and are ineffective in decreasing the risk of
understanding of the correct techniques such injuries [30], but one most keep in
used for each move. Thus, in order to mind that many of these studies were done
incorporate resistive exercises in ones on younger populations and thus the results
daily schedule, one must search for the of such studies may not be attributable to
more practical and cost-effective measures other age groups [18]. Altogether, it seems
[23]. that performing these trainings accurately
If no contraindication is present, type II can result in increasing muscular flexibility
diabetics must practice resistive exercises and joints range of motion. Since diabetes
for at least 2 sessions a week or up to 3 may be associated with increased limitation
sessions per week. In each practice session, of joints range of motion, probably use of
10 Hassabi et al.: Exercise Prescription in
neuropathy [34]. Many of the aerobic must discard any worn out footwear.
exercises like walking and jogging require Diabetic patients may choose shoes
appropriate shoes. Shoes, if inappropriate, appropriate for the type of their intended
may result in impaired blood perfusion to exercise. In regard, the surface on which
the foot and inflammation resulting from patient is to exercise should be considered
recurrent focal pressure. The combination when choosing the footwear [35]. A good
of aforementioned mechanisms may even time to ensure if patient has obtained
lead to foot ulceration. If patient fails to appropriate footwear at the time of physical
recognize and treat diabetic foot ulcer, it exam prior to beginning the exercise
may easily become infected and deepen routine [36].
further [35].
Diabetics with neuropathy must wear shoes Adequate hydration: It is prudent to
with thick bottom layer. They may also adequately hydrate diabetics during
frequently examine the internal surfaces of exercise. Dehydration may lead to various
their shoes and look for foreign bodies. detrimental effects in a diabetic. First,
Walking barefooted on hot sidewalks, blood glucose concentration will increase
around the pool or inside hot showers may as the body dehydrates during exertion.
be dangerous as it may lead to severe burns Second, diabetics with autonomic
on their soles. neuropathy are prone to hypotension
For aerobic exertions, the American following exertion if dehydrated. Also
diabetic association recommends use of given that most of the type II diabetics are
silica gel or air orthoses in the mid sole part obese and obesity is a precursor for
of shoes in order to minimize foot injuries. dehydration and heat exhaustion, thus it is
Also recommend is use of polyester or essential to pay close attention to maintain
cotton blend stockings, which helps to keep adequate hydration during exercise.
foot dry and prevent it from blistering. One Adequate rehydration may be achieved by
must always wear clean and dry stockings drinking 500 ml of fluids about 2 hours
when exercising and then exchange the prior to the activity. During the exercise as
sweaty stockings and dry up his feet after well, one must drink fluids frequently with
each session. The moist stockings are short intervals, enough to compensate for
hazardous given that it may become the amount of fluid lost with perspiration.
infected with fungi. Caution is advised with exertion in the cold
Impaired blood perfusion to the feet as a or warm climate [37]. Diabetics must avoid
result of stiff footwear is a common exercising in the hot and under direct sun
etiology for foot injuries. Many times, light [5].
when shopping for shoes, diabetics with
neuropathy may assume that the shoe they
are trying is too tight and thus request a Exercise precautions in diabetics
smaller size shoe. Tight footwear is affected by diabetes complications
dangerous given that it may easily lead to
ischemic pressure ulceration. These Since there are limited studies about the
patients need to wear shoes with enough pros and cons of exercise in patients who
space around the toes to prevent friction suffer from complications of diabetes, thus,
and blistering in the toes. In general, leather most of recommendations in this field are
is preferred to plastic given that it molds to based on expert opinion [18]. Diabetic
the foot and allows air exchange between complications do not contraindicate
the foot and the surrounding air. New exercising as the benefits of light to
footwear must be initially worn for short moderate intensity exercise outweigh its
periods until they soften and then foot must potential hazards [5]. Here we will review
be evaluated for any pressure points. One the potential complications associated with
12 Hassabi et al.: Exercise Prescription in
large groups of muscles with light to prohibited from physical activity, but as a
moderate intensity (like bicycling, biking, rule of thumb, physician must always
etc). Recommendations for hypertensive evaluate this group, prior to any change in
patients must also be followed. the level of daily activities and modify the
prescribed exercise routine as needed.
For the physicians, using simple phrases,
CONCLUSION like walk somewhat more, are not
beneficial. Patients must be adequately
Exercise is an important measure of educated in this regard. The prescribing
primary and secondary prophylaxis in type physician must tailor an exercise routine
II diabetes and it also helps regulate blood which fits patients physical condition and
sugar in these patients. Other than also is compatible with her/his
regulation of glucose metabolism, regular psychological and social situations. This
exercise harbors many somatic, mental and will improve patients motivation and
social benefits in diabetics. compliance with the prescribed exercise
While nowadays, even those diabetics who routine.
suffer from diabetes complications are not
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