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While exercise has not been shown The treatment of diabetes mellitus uses three modalities:
to provide long-term improvements diet, drugs, and exercise. This review will address general
exercise prescription guidelines for individuals who have in-
in blood glucose control, it has been
shown to delay or prevent secondary sulin-dependent diabetes mellitus (IDDM) or non-insulin-
dependent diabetes mellitus (NIDDM). Basic metabolic
conditions associated with diabetes. and hormonal responses to exercise in normal populations
Exercise also offers significant and in individuals with diabetes mellitus will also be dis-
psychological gains by allowing cussed, as will the benefits gained from exercise for those
both IDDMand NIDDMpatients who have diabetes.
to participate in normal
Goals and Benefits of Exercise
recreational or competitive The primary reason for implementing an exercise program
activities. A properly designed for patients with diabetes is to provide them with the oppor-
exercise prescription begins with the tunity to lead a normal active life-style in recreational or
education of the patient, including a competitive sports. In addition, exercise provides the neces-
sary activity that can prevent or delay long-term pathologies
thorough understanding of the associated with diabetes. The benefits to be gained from ex-
effects of exercise, the demand it ercise by those with diabetes are still controversial. The de-
places on the metabolic processes, gree of improvement or prevention varies with each
and the necessary adjustments that individual and depends upon the duration of the disease
must be made to maintain and the state of the person’s metabolic control.
Because studies have not shown long-term improvements
normoglycemia. A stress test is a in blood glucose control with exercise, exercise is not gener-
recommended preliminary. ally prescribed for the sole purpose of reducing blood glucose
levels.’ Nevertheless, studies have demonstrated significant
benefits from exercise in subjects with diabetes who have un-
dertaken a regimented exercise program of appropriate inten-
sity and duration. Exercise can delay or prevent premature
cerebral, coronary, and peripheral vascular diseases that com-
monly occur in diabetic individuals under 30 years of age. 2-4
Furthermore, poor blood lipid profiles associated with diabe-
tes-most often with NIDDM-have been shown to im-
prove with exercise. Reductions in triglyceride, low-density
lipoprotein, and very-low-density lipoprotein levels and in-
creases in high-density lipoprotein levels are commonly noted
with exercise.3 In addition, exercise has been shown to have a
lowering effect on blood pressure. Individuals who become
hypertensive as a result of diabetes or medications used in its
treatment can also reduce this potentially pathological risk
factor with physical activity2
Several specific physiologic improvements in persons with
diabetes have been attributed to exercise. Exercise increases
the number, sensitivity, and binding capacity of insulin recep-
tors, which helps reduce insulin requirements for maintaining
normoglycemia..’4.5 Because hyperinsulinemia appears to be
related to vascular diseases and may stimulate arterial smooth vous system. It has inhibitory effects on the release of insulin
muscle proliferation, accelerating the atherosclerotic process, and facilitates the release ofglucagon.6 As a result, the produc-
a reduction in the need for insulin would decrease the risk for tion of glucose is increased and blood glucose levels become
these pathologies and provide psychological support to the elevated.
individual.z2 These hormones and their combined effects are utilized to
Diabetes has also been associated with blood coagulation provide fuel to the body upon demand. When the body is at
abnormalities, which contribute to the incidence of cardio- rest, fat provides the primary fuel source. As energy demand
vascular disease.3 Under these circumstances, which are not increases beyond the intensity at which fats can provide fuel
completely understood, fibrinolytic capabilities decrease and fast enough, the need for glucose or carbohydrate sources in-
an enhanced ability for platelet aggregation occurs. Studies creases. Exercise can increase energy demand by more than
suggest that significant improvements in fibrinolytic re- 10 times the body’s resting values, and the sensitive metabolic
sponses and other coagulation properties occur with regulatory system must be able to make appropriate adjust-
exercise.; ments to meet these needs.
With the onset of exercise (and an increase in energy me-
Energy Metabolism and Hormonal Responses tabolism), cellular glycogen is converted to glucose, and blood
A general understanding of normal energy metabolism and glucose begins to enter the cells more rapidly to meet energy
hormonal responses during exercise is necessary before an demand. Concomitantly, an increase in sympathetic nervous
exercise prescription for an individual with diabetes can be system discharge increases the secretion of glucagon, inhib-
designed. The regulation of energy sources is a complex and iting insulin secretion and slightly reducing plasma insulin
sensitive system that is primarily monitored and regulated levels. Glycogenolysis and gluconeogenesis are stimulated,
by the pancreas, which is capable of producing hormones and glucose production is enhanced. The reduction in insulin
that play a key role in the regulation of blood glucose levels does not disrupt the uptake of appropriate amounts of glucose
and carbohydrate metabolism. Within the pancreas, alpha into the cells because increased blood flow to the working
cells secrete glucagon, beta cells secrete insulin, and delta muscle transports more of the available insulin to the area for
cells secrete somatostatin, all of which effect the delicately use, and sensitivity of insulin receptors is also enhanced. Fur-
balanced blood glucose level. The major function of these thermore. increased sympathetic nervous system activity may
hormones is to increase the rate ofcellular reactions or trans- have an inhibitory effect upon pancreatic secretion of insulin.
port mechanisms. The primary function of insulin is to facil- These processes actually lower the requirement for insulin
itate the transport of glucose into muscle or adipose cells. during exercise and provide the necessary adjustments in glu-
This enhanced transport occurs when insulin attaches to a cose production to match peripheral utilization. 1,6-1
specific cell receptor, and blood glucose is carried across the
cell membrane into the cell for energy.’~6 Any glucose that is Diabetes, Exercise, and Fuel Homeostasis
not used immediately is stored as glycogen in muscle cells Fuel homeostasis at rest and during exercise is compro-
and as fat in adipose cells.’~6 mised in individuals with diabetes. Those with IDDM lack
As blood passes through the pancreas, glucose levels are sufficient levels of insulin because of the reduced secretion
monitored. If blood glucose levels are high (hyperglycemia), of insulin by the beta cells of the pancreas, thus appropriate
insulin is secreted into the blood stream. Insulin will inhibit amounts of glucose fail to enter the cells, creating a state of
the mobilization of fat and the breakdown of glycogen, and hyperglycemia. Those with NIDDM, on the other hand,
blood glucose will be transported into the cells for use or stor- have sufficient levels of insulin but lack the ability to utilize
age, lowering the glucose levels. On the other hand, if blood it because the insulin receptor sites on the cells have become
glucose levels are low (hypoglycemia), insulin secretion de- resistant to the absorption of the insulin and hyperglycemia
creases, enhancing fat mobilization and glycogen breakdown results.
to increase glucose availability and raise blood glucose levels. Individuals with IDDM offer the greater challenge for pre-
This balancing occurs to maintain homeostasis and scribing appropriate exercise because their treatment usually
normoglycemia. ’.6 requires some form of insulin supplement. These individuals
must adjust insulin dosage or carbohydrate intake before and
Counterregulatory Hormones after exercise to maintain normoglycemia during and after
A general understanding of the function of the counterregu- exercise. In IDDM, the most difficult problem encountered
latory hormones glucagon and epinephrine is also necessary with exercise is for the body to achieve a low but adequate
to prescribe exercise for people with diabetes. Glucagon level of plasma insulin so that glucose can be absorbed into
serves as an &dquo;insulin antagonist&dquo; whose major function is to the cells and produced to meet demand. Therefore, individu-
increase blood glucose levels. This process is achieved by als with IDDM must be under good metabolic control, with
glucagon’s stimulating effects on glycogenolysis (the break- an established regimen of diet and insulin dosage prior to par-
down of glycogen into glucose) in the muscle and gluconeo- ticipation in an exercise program so that appropriate manipu-
genesis (the production of glucose from noncarbohydrate lations can be made in either insulin dosage or diet to satisfy
sources) in the liver. The enhancement of these two the demands of physical activity.
processes increases the availability of glucose for energy. ’,6 An underestimation of insulin needs before exercise can
Epinephrine is another counterregulatory hormone that create a hypoinsulinemic condition that results in hyperglyce-
plays a significant role in the regulation of normoglycemia mia. Fat metabolism and hepatic glucose production will in-
during exercise. Epinephrine is released from the adrenal crease as the body tries to compensate for the reduction in the
gland and terminal ends of neurons of the sympathetic ner- uptake ofglucose into the cells. Lack of carbohydrate metabo-
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177
Summary
The treatment of diabetes is a complex procedure that in-
cludes several methods and combinations of techniques to
achieve appropriate levels of blood glucose for normal en-
ergy metabolism and to reduce secondary complications. It
is essential for physicians, health professionals, and patients
to have open lines of communication with one another so
that an effective treatment plan can be designed.
The use of exercise in the treatment of IDDM and NIDDM
Special Considerations IDDM patients with microvascular appears to benefit individuals
by delaying or preventing
complications such as proliferative retinopathy or nephro- pathologies associated with the disease and allowing them to
pathy should avoid high-intensity activity that elevates sys- lead a normal active life-style. A properly designed exercise
tolic blood pressure above 180 to 200 mm Hg for substantial prescription begins with the education of the patient. A thor-
periods of time. The exercise prescription for these individ- ough understanding of the effects of exercise, the demand it
uals should take into consideration their blood pressure places on the metabolic processes, along with the necessary
responses adjustments that must be made to maintain normoglycemia,
Individuals with peripheral neuropathy experience loss of are necessary for a safe and effective treatment protocol.
sensory function, and they should avoid traumatic full- A formal exercise prescription should be preceded by a
weight-bearing exercise. Their mode of activity should be lim- complete stress test used for diagnostic purposes in those over
ited to cycling or swimming, for example. Furthermore, the age of 35 or for functional measurements for those under
proper shoes and socks should be worn during exercise, and 35. Once a regimented daily and weekly treatment plan has
the feet must be examined frequently2J been designed and appropriate mode, intensity, frequency,
Neurological complications such as autonomic neuropathy and duration of exercise established, individuals can begin to
will impair normal sympathetic and parasympathetic func- make slight variations in the protocols to enhance their active
tion. Cardiovascular responses such as decreased exercising daily living, thus helping them to lead normal, healthier lives.
heart rate, hypotension, irregular thermoregulation, and diffi-
culty sensing the signs of hypoglycemia are common clinical I would like to thank the staff at Pro-Form for their support and assistance
signs. Proper exercise prescription and supervision for these throughout the development of this manuscript and especially thank
individuals are essential.2J Peggy Ann Herzberg, RN. AT, for her support and guidance.