Managing the Medicine of
Choice: Physical Activity &
Diabetes
Virginia Kay Mirenzi,
MS, RD, CDE, LDN, HFS
Physical Activity & Diabetes
1.
2.
3.
Identify resources for assessing
current level and starting a physical
activity plan
Discuss effective methods of
motivating and monitoring change
in physical activity with diabetes
Discuss key strategies in managing
glucose control & physical activity
Benefits of Physical Activity in DM
Increased insulin
sensitivity
Reduced risk of CVD,
HTN, obesity
Increased life expectancy
Increased aerobic
endurance, muscle
fitness, flexibility &
balance
Lower A1C
Enhanced self-esteem
and sense of well being
Active American Adults
58% of adults
without Diabetes
are physically
active
39% of adults with
Diabetes are
physically active
Exercise is Medicine
http://exerciseismedicine.org
“Calling on all health care providers
to assess & review every patient’s
physical activity program at every
visit.”
Pre-exercise Evaluation
Risks
Hyperglycemia
Hypoglycemia
Musculoskeletal injury
Cardiovascular
accident (angina, MI,
dysrhythmia, sudden
death)
Deterioration of
underlying retinopathy
and nephropathy
Safe exercise can
be complicated by
presence of DM
related
complications:
CVD
HTN
Neuropahty
Microvascular
changes
Assessment for Physical Activity
Clinical history & Labs
Exercise & Weight history
Assess barriers to PA
Physician evaluation
Podiatrist & Ophthalmologist checks
Exercise Testing
ECG vs. Exercise Stress Test
Participant Evaluations
Physical Activity Readiness
Questionnaire (PAR-Q)
The AHA/ACSM Health/Fitness
Facility Pre-participation Screening
Questionnaire
Low intensity PA
Use clinical judgment
No evidence pre-exercise testing
necessary, as CVD diagnostic tool,
may be barrier
Walking or indoor cycle at low
intensities great starting PA
Beauty of a Brisk Walk
50% of VO2max
Muscles using 50% fat & 50%
glucose: burns fat, lowers BG
Physically safe
Good CV fitness
Talk while exercise!
Evaluation before PA
Anything more intense than brisk walking:
physician evaluation
ECG exercise stress testing
Age > 40 yr
Age > 30 yr with DM > 10 yrs or
HTN, Smoking, dyslipidemia, retinopathy,
nephropathy
CAD or PAD
Autonomic neuropathy
Advanced nephropathy
Using Evaluation to ID current
PA capacity & progression
Stress Testing : Target Heart Rate
range & Intensity
Podiatry Exam: Type/ Mode
Ophthalmology Eval: Type /Mode
Kidney labs: Type/Mode
Enlist Experts for Exercise
Prescription / Partner with Trainers
ACSM www.acsm.org
Market place
Current Fact Sheets
Roundtables
Position Statements
Journal Articles
5 Stages of Physical Activity
Couch Potato “I am inactive & I plan to
stay that way.”
Inactive Thinker “I am inactive but I am
thinking about becoming active.”
Planner “I am taking steps to start to be
active.”
Activator “I am active but not as active as
I should be.”
Active Exerciser “I am regularly active
and have been for some time.”
What stage are you now?
Battle of Wills
Plato: “We have a rational charioteer who
has to rein in the unruly horse that barely
yields to horsewhip and goad combined.”
The brain has 2 independent systems
at work at all times
Emotional side: instinctive, feels pain
and pleasure, language of feelings
Rational side: reflective or conscious
system, deliberates and analyzes, looks
into the future
Jonathan Haidt in Happiness Hypothesis &
Chip & Dan Heath in Switch.
Elephant:
Emotional side
Rider:
Rational side
To Change Behavior
Direct the Rider: What looks like
resistance is often a lack of clarity
Motivate the Elephant: What looks
like laziness is often exhaustion
Shape the Path: What looks like a
people problem is often a situation
problem
The struggle between Elephant &
Rider
Experiment part #1: Radish vs. Chocolate
Experiment part #2: Solve problem, High
School vs. College students
Persistence on Unsolvable Puzzles
Time (min)
attempts
Radish
8.3
19.4
Chocolate
18.9
34.3
No food /
Control
20.9
32.8
J Per Soc Psy, 1998, 74, 5
Change is tiring!
Dozens of studies demonstrate the
exhausting nature of self-supervision
Wedding registry
Ordering new computer
Restrain emotions while watching movie
The bigger the change, the bigger the
drop in self-control & problem solving
afterwards
Willpower: Rediscovering our
greatest strength by Roy Baumeiser
& John Tierney
Marshmallow experiment
Muscle to improve with practice
Uses energy
Decision Fatigue
= Ego depletion
Brain scans reveal ego depletion with decision making &
suppression of wants, increased activity in nucleus
accumbens, reward center and less activity in amygdala,
which helps with impulse control
In times of heavy decision making and lots of control, food’s
appeal is stronger while impulse control weakens
Self-control tasks lower circulating blood sugars and
increase craving for sweets
Studies suggest many people spend 3-4 hours a day
resisting desires (food, sleep, Facebook, spend $, sex, TV)
lowering ability to control self-care behaviors
Recognize the impact on people with DM
Direct the Rider
Follow the Bright Spots: Spark the
hope
Script the critical moves: Stop
decision paralysis
Point to the Destination: Give
picture of short term and longer term
endpoints
Direct the Rider with DM & PA
Follow Bright Spots: Give specific
examples of other pts success,
Support groups
Script the critical moves: a specific
behavior that is within the pts control
and abilities, like walk at lunchtime
Point to the Destination: Lower BG,
drop a clothes size, lower A1c
“Darryl”
61 yr T2DM
Dx at 40 years old
Obese most of
adult life, up and
down weight,
increasing meds,at
55 yr ,A1c = 8.1
“Darryl” at 55 years old
Became an
exerciser
Started with 15
minute walk, 3x/wk
Joined Weight
Watchers
“Darryl” at 61
Active lifestyle:
cycles, swims, walks, snow-shoe
walking in winter, kayaking
Maintains goal of 60 min 5 x / wk
A1C = 5.5 %, no DM meds
Became Weight Watchers leader
Motivate the Elephant
Find the Feeling
Shrink the Change
Appeal to Identity
Grow Your People
SEE-FEEL-CHANGE
Motivate the Elephant: DM & PA
Find the Feeling: What engages
change for person?
Shrink the Change: Reframe
Appeal to Identity: Rename
Grow Your People: Journey
Weight Management Group
Grandma training
Wear wedding rings
Vegetable & water contest
Address one habit a month
Work time athletes
Not on a diet, on a Health Journey,
not a destination but a path
“Debbie”
T2 Dm, dx at 37 yrs
46 yrs
DM Meds: glipizide ER
10mg. BID,
glucophage 1000mg
BID
Ht 63.5 in., Wt 273 lbs.
A1c: 11.2%
Endo ready to start
insulin therapy
“Debbie”
“Debbie the Exerciser”
Chose dancing at home
Record keeping helped see exercise
impact
Phone follow-up, next day & 2 wks
4 wk follow up appt.
Support Group
“Debbie” 3 month Follow-up
A1c = 6.5%
Weight decreased 10 lbs, dropped 2
dress sizes
No changes in DM meds, not add
insulin at this time
Added walking at lunch & bought
some home equipment
Shape the Path
Tweak the
Environment: Map
Build a Habit:
Action Triggers
Rally the Herd:
Behavior is
contagious
Shape the Path: DM & PA
Tweak the Environment: Equipment in
the TV room, Sit on exercise ball at work
Build a Habit: Set up Action
Triggers, like gym bag in car, walking
shoes at work
Rally the Herd: Social network, web
sites with support & e-mail, Support
Group, Group Fitness
Connected Health
Heart Monitors
Pedometers
Striv
Jawbone
FitBit
Basis Band
Nike Fuel Band
Apps
On-line
Myfitnesspal.com
Sparkpeople.com
“Donna”
 57 yr
T2DM, dx at 48 yr
DM Meds: Levimir 50
units am, 52 units pm,
metformin 500 mg am,
1000 mg pm, Novolog
flexpen base 7 units,
sliding scale
61 inches, 217 lbs
No exercise plan
A1C: 8.1%
“Donna”
Team approach
Screened and tested for exercise
Personal Trainer: Twice week, Cardio
start, and increase to RT and Cardio
RD/CDE: weekly, then monthly, Carb
counting, meal timing
Therapist: weekly and then monthly
PCP: every 3 months
“Donna” 3 month follow-up
2 days with trainer,60
minutes, combo of
aerobic & RT
2 days yoga
3 days home cycle
with interval training:
5 min Warm,
30 sec.high intensity,
60 sec. moderate,
repeat, 9 min currently
5 min Cool
Lost 20 pounds
A1c = 6.9 %,
Levimir:40 units
BID
Novolog: base of 3
units sliding scale
CDE, PCP,
Therapist: every 3
months
Pathways of glucose into muscle
Insulin dependent BG uptake into skeletal
muscle at rest & post-prandially, impaired
in T2DM
During Physical Activity, contractions
increase BG uptake to supplement
intramuscular glycogenolysis, not impaired
by insulin resistance or T2DM
Changes in fuel as Exercise
Muscle glycogen provides the fuel
As intensity increases and glycogen stores
deplete, increased uptake of circulating
BG, with FFA from adipose tissue
Switch from mostly FFA at rest, to blend of
fat, glucose & muscle glycogen with PA
Intramuscular lipid stores used during
longer duration activities and recovery
As duration increases enhanced
gluconeogenesis
Acute changes in muscular insulin
resistance
Most individuals experience a
decrease in BG during mild- moderate
intensity activity for 2 – 72 hours
BG reductions related to duration,
intensity, pre-exercise control and
type training
Acute improvements found at all
levels of intensity
Aerobic Exercise Effects
Moderate aerobic exercise improves
BG and insulin action acutely
Risk of hypoglycemia minimal without
use of exogenous insulin or insulin
secretoagogues
Brief, intense aerobic exercise raises
plasma catecholamin levels
Hyperglycemia can result for 1 – 2hours
Effects of Aerobic & RT on A1C
levels in patients with T2DM
A randomized Controlled Trial
Among pts with T2DM, a combo of
aerobic and RT compared with nonexercisers improved A1C, not
achieved by aerobic or RT alone
» JAMA Church, et al 2010, Vol 304, no. 20
“Daniel”
49 yr T2DM
Dx at 43 yr, DM education,
kept A1c in 6.5 – 7.1 % range
until recently, now 8.5%
Eats very low carbs, Ht 73.5
inches, wt- 214 lbs.
Not monitoring BG, no
exercise
Metformin ER 750 mg BID,
Glimepiride 4 mg. BID
5 kids, busy Executive
Body Composition with Weight Loss
Younger Adults:
Gain Weight:
30% Lean Mass
Lose weight:
30 – 50% Lean Mass
Older Adults:
Gain Weight:
greater% is fat
mass
Lose weight:
usually > 50% Lean
Mass
Changes in body with less muscle
and more fat
Decreased metabolic rate
Decreased Aerobic capacity
(VO2max)
Insulin resistance
Sarcopenia
Age related loss of skeletal
muscle mass
Evans, William. Sarcopenia and age-related changes in body
composition and functional capacity, J. Nutr., 123; 465-468, 1993
Sarcopenia
Reduced protein reserves
Decreased strength and functional
capacity
Reduced aerobic capacity
Reduced energy requirements
Leads to other health issues
Sarcopenia by age
40 – 50 year old:
Loss of muscle motor units accelerates
Decreased sprinting capacity
Decreased VO2max even with training
Concomitant increase in fat mass
Visceral fat increases
Adipokine levels increase
Insulin resistance
Sarcopenia by age
60 – 70 year old:
Reduced PA
Reduced androgen production &
menopause
Insulin resistance
Inflammation with increases total body
and & visceral fat
Nutrient deficiencies (increased need for
protein, Vit. D and other micronutrients
Sarcopenia by age
70 years old plus
Further reduction in PA
Weakness & accelerated loss of VO2max
Inactivity due to illness, hospitalization,
depression, fear of falling, mild cognitive
impairment
Reduced muscle protein synthesis
Increased muscle protein breakdown
secondary to inflammation and chronic
diseases
Resistance training reduces whole body
protein turnover and improves net protein
retention in young males
Appl Physio Nutr Metab 31, 557, 2006
7
6
5
Nitroge
n
Balance
4
3
2
1
0
Pre Post
“..dietary
requirements for
protein in novice
RT athletes are not
higher, but lower,
after RT..”
Challenges of T1DM & PA
Hyperglycemia
Hypoglycemia
“David”
55 yr old
T1DM dx at 37 yr
Animas Pump
Cyclist
A1c = 6.9 %
“David”
Adjustments to pump
Adjustments to food
Guidelines for Food Adjust & PA
Short duration:
30-45 minutes,
Walking ½ mile, biking 1
mile
< 100mg 10-15 g Carb/hour
Moderate intensity:
30-60 minutes,
Tennis, swimming,
jogging, cycling, golfing
Strenuous:
60 minutes,
Football, hockey, soccer,
swimming
<100mg
>100mg
none
20-50g/hour
100-180mg/dL
>180 mg/dL
<100mg/dL
15g/hour
none
50g/hour
100-180mg/dL
25-50g/hour
180-250mg/dL
10-15g/hr
Insulin Adjust for PA Rich Weil,Med, CDE
Duration &
intensity
70-99mg/dL
100-179 mg/dL
180-250 mg/dL
Short, low:30
minutes walk,
cycle or yoga
Reduce insulin
by 1 unit
None
none
Moderate/Moder
ate: 30-60 min of
fast walk, tennis,
jog, swim
Reduce insulin
by 1 unit
Bg 100-120,
reduce by 1
unitNone for BG
121-179
none
Moderate
duration/high
intensity(30-60
min, running,
kickboxing
Reduce by 2
units
Reduce by 1 unit
none
Long duration/
high intensity
(60 + min)
Reduce by 1 unit Reduce by 1 unit
for every hour&
for every hour&
retest q hr
retest q hr
Reduce by 1
unit
Management of T1DM and PA
Personalize
Pump: Reduce basal by 50% to start
MDI: Decrease meal bolus prior by 20-50%
Adjust with trial & error
Water & sports drink during
Check BG and respond with Carbs
Record, adjust & learn
Practice adjustments & fuel before competitive
events
Summary of PA & DM guidelines
BG Management with PA
BG Target : 90 –
180 mg/dL
Personalize Target
Check pre, during
and post PA
Carry snacks,
water, Hypo
treatment, BG
meter
Combined aerobic and RT &
Flexibility training (yoga/Tai Chi)
Combined may be more effective:
RT contribute to BG uptake by increased
muscle mass
Aerobic activity enhances BG uptake
independent of muscle mass or aerobic
capacity changes
Studies with yoga & tai chi, mixed,
small sample sizes and varying forms
preclude conclusions
Chronic Effects of Exercise Training
Both aerobic and RT improve insulin
action, BG control and fat oxidation
and storage in muscle
Blood lipid responses mixed, may see
reductions of LDL
Combo of aerobic exercise and diet
may give the best improvements in
triglycerides, HDL and LDL. Look AHEAD
Study
Body weight: Maintenance & Loss
Most successful programs involve
combo of diet and PA & behavior mod
PA alone to improve BG control &
reduce CVD risk = 150 min/week
PA alone for weight loss > 2000
kcals/wk or 7 hr/wk
Frequency of Aerobic Activity
3 – 6 / week
No more than 2
consecutive days
off
Intensity of Aerobic activity
Moderate intensity
40 – 60% VO2 max
Vigorous intensity
>60% VO2max
Duration of Aerobic activity
Individuals with T2DM should engage in a
minimum of 150 min/ wk of moderate
intensity or greater as able
In bouts of at least 10 minutes, 30-60
minutes as goal
Mode of Aerobic Activity
Any form of aerobic exercise that uses
large muscle groups and causes sustained
increases in HR
Variety is recommended
Rate of Progression
Currently, no study on individuals with
T2DM compared rates of progression in
intensity or volume
Gradual progression recommended
Frequency of Resistance Training
Twice a week on non-consecutive days
Increase to three days / week
Work in with aerobic activity
Intensity & Duration
Moderate is 50% of
1 Repetition
maximum (1-RM)
Vigorous is 7580% of 1-RM, in
athletes with stable
diabetes
10 – 15 reps to near
fatigue per set
Progress to 8-10
reps heavier wts.
One set to start,
increase to 3 sets
Mode of RT
Resistance machines and free
weights result in fairly equivalent
gains
Training session include 5 – 10
exercises involving major muscle
groups
Progression of RT
Occur slowly
Increase in weight/resistance first, only
once target reps per set
Then increase number of sets, from 1, to 2,
to 3
Then increase weight, and repeat
Progression for 6 months to 3x/wk
sessions of 3 sets of 8 – 10 reps at 75-80%
of 1-RM of 8-10 exercises is optimal goal
Flexibility Exercises
Stretching:
helps avoid stiff, sore muscles
helps perform ADL easier
helps avoid injuries
Perform when muscles are warm
Hold a stretch 30 – 60 seconds,
repeat
SMART Goals
 Specific: Walk at Lunch time
Measurable: 30 min, Tues, Thur, Fri
Adjustable: start with 15 min, increase by
5 min each week
Realistic: Are you confident that you can
achieve the goal you chose?
Time frame: this plan is for the next 4
weeks
Evaluate & Set new goal
Patient Resources
For weight loss & exercise tips:
www.sparkpeople.com & www.dLife.com
National Institute on Aging
Go4Life book and DVD
BD web site, easy & reliable
www.bd.com/us/diabetes/learningcenter
Sample workouts with animation of exercises