Exercise &

Diabetes Mellitus
Abdulrahman Mohammed AL-Howikan

Director of Cardiopulmonary Exercise Testing And

pulmonary function test Lab, Medicine dep., College of
Medicine
King kalied university hospital

Diabetes Educator Course, KA Med City, April 2007 KSU

 Definitions 1

Physical Activity
Any bodily movement produced by the
skeletal muscles resulting in energy
expenditure above resting state.

Physical Fitness
A set of attributes that people have or
achieve, which relates to the ability to
perform physical activity.
Caspersen, et al., Public health Rep,1985 KSU
 Definitions 2

Metabolic Equivalent (MET)

The amount of energy expended during

exercise relative to the energy expenditure
during rest.
Energy expenditure during rest = 1 MET
= 3.5 ml of O2 / kg. min
= 1 kcal / kg. hr

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 Classification of Exercise

Aerobic exercise:
Endurance type exercise, rhythmic,
sustained for sometimes. Example:
Walking, jogging, running, cycling, swimming, etc…

Strength (Resistance) exercise:

Weight training with free weight,
machine, elastic rope, calisthenics, etc…

Flexibility exercise:
Stretching exercise.

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Physical Activity Intensity in MET

Light: Less than 3 MET

Moderate: 3 – 6 MET

Vigorous: Above 6 MET

CDC, 1996 KSU

 Moderate & Vigorous Intensity
Physical Activities

Moderate:
Brisk walking, Recreational swimming,
Volleyball, Slow aerobics, Moderate cycling
Gardening, Tennis-double, Badminton etc..

Vigorous:
Jogging, Running, Tennis-single, Basketball,
Rope skipping, Squash, Fast aerobics, Fast
cycling, Stepping, Soccer, etc
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 What is the Amount of Physical Activity
that Promotes Health?

 Moderate Intensity Physical Activity.

 Energy Expenditure = 3 - 6 MET
 That is: ≥ 30 min/day, ≥ 5 days/week.
 150 min. per week.
ACSM, 2000; CDC, 1996

 ≥ 1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000

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 Health-Related Dimensions of Physical Activity
‫أبعاد النشاط البدني المعزز للصحة‬

.)Caloric Expenditure( ‫الطاقة المصروفة‬ •

.)Aerobic Intensity( ‫األنشطة الهوائية المرتفعة الشدة‬ •
.)Muscular Strength( ‫القوة العضلية‬ •
.)Flexibility ( ‫المرونة‬ •
‫األنشطة البدنية التي يتم فيها حمل الجسم‬ •
.)Weight-bearing physical activity(

ACSM, 2000
Caspersen, et al., 1998
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 Exercise
& Diabetes

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Can Exercise Prevent
or Delay Diabetes ?

Evidences from
Randomized Clinical Trials
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 Exercise in the Prevention of Diabetes
Participants are either normal or have + GTT
Malmo Sweden 260 males Eriksson & Lindgarde,
Diabetologia, 19991
Study (6 yrs)
Da Qing, China China 577 males & Pan, et al,
Females (6 yrs) Diabetes Care, 1997

The Nurse’s USA 70,000 Hu, et al.,

Health Study Nurses (8 yrs) JAMA, 1999

Finnish Finland 523 males & Tuomilehto, et al., N

Experimental Engl J Med, 2001
Females (4 yrs)
Study
Diabetes USA 3234 males & Diabetes Prev. Program
Research Group,
Prevention Study Females (3 yrs) N Engl J Med, 2002

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KSU
Exercise in the Prevention of diabetes
Summary of the Results

Moderate Physical Activity

Performed Regularly for 120 – 200
min. per week Reduces the
Incidence of Diabetes in People
Predisposed to Diabetes.

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Exercise in the
Management of
Diabetes

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 Exercise & Type 1 Diabetes

Improves physical fitness.

Increases self confidence.
Improves CV function & CHD risk profile.
It has no direct effect on glucose control.
Proper timing of Exercise & Insulin.
Avoid strenuous exercise before bed time.

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 Exercise & Type 2 Diabetes

Improves physical fitness & reduces fat %.

Improves CV function & CHD risk profile.

Increases self confidence.

Improves glucose control:

 Improving insulin sensitivity.
 Increasing Glu T4 (glucose transporters).

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Response to 100 g of glucose in mild Type 2 Diabetics
12 months of Training
20
Plasma Glucose (mmol/l)

15

10

5
Before After
0
0 30 60 90 120 150 180
Time (min)
Holloszy, et al. Acta Medica Scand 1986, 711: 55-65 KSU
Response to 100 g of glucose in mild Type 2 Diabetics
12 months of Training
1600
Plasma Insulin (pmol/l)

1200

800

400

Before After
0
0 30 60 90 120 150 180
Time (min)

Holloszy, et al. Acta Medica Scand 1986, 711: 55-65 KSU

 Exercise
Prescription
for Diabetic
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 Exercise Prescription for Diabetic 1/4

Aerobic activity for 30 min. extended (gradually)

to 60 min. every day or most days/week.

HR during activity should be gradually

increased to reach 60 – 70% of HR max.

Exercise session should include 5-10 min. of

warm-up and a 5 min of cool-down.

Exercise must involve most major muscles in

both lower and upper parts of the body.

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 Exercise Prescription for Diabetic 2/4

Exercise must be regular. Benefits are

diminished after 1 -2 weeks of stopping .

Moderate intensity weight training program

is recommended to maintain muscle strength
( 8-12 repetitions 2 times /week).

For those with feet problems, avoid running.

Alternate between walking, swimming, and cycling.

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 Exercise Prescription for Diabetic 3/4

Use proper shoes, with silica gel or air-filled

soles, and always keep feet dry.

When using insulin, avoid exercise if glucose

levels below 100 mg/dl or above 250 mg/dl.

Do not inject insulin into a body part that is

expected to be used during exercise.

Avoid dehydration by keeping your body

always hydrated.

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Graded Exercise Testing for Diabetic 4/4

It is recommended before any moderate to

high intensity exercise, especially if:
 Age is > 35 yrs.
 Type 2 diabetes for > 10 yrs duration.
 Type 1 diabetes for > 15 yrs duration.
 Presence of any CHD risk factors.
 Presence of microvascular disease
(retinopathy, nephropathy).
 Presence of peripheral vascular disease.

ADA Position Statement, Diabetes Care, 2002 KSU

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 Exercise
Prescription for
Special Cases
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Diabetic with Peripheral Neuropathy

Peripheral neuropathy may results in loss

of sensation in the feet.
Repetitive exercise on insensitive feet can
lead to ulceration & fractures.
Limit weight-bearing exercise (Treadmill,
Prolonged walking, Jogging, Step exercise, etc..)
Alternative exercises are: Swimming,
Bicycling, Arm exercise, Chair exercise, etc..

Use proper shoes, and always monitor the feet.

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Diabetic with Autonomic Neuropathy

This condition may limit exercise capacity &

increase the risk of CV event during exercise.

Hypotension and hypertension are more

likely to develop after vigorous exercise.

Those patients may have difficulty with

thermoregulation:
 Avoid exercise in hot or cold environments.
 encourage adequate hydration.

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Hypoglycemia during or after Exercise

It will most likely occur if the patient:

 Takes insulin or diabetes pill.
 Skips a meal.
 Exercises for a long time.
 Exercises strenuously.

If it occurs, what can be done?

 Patient must eat a snack before exercise, or.
 Adjusts the medication dose.
 Remember: Patient should always carry a source
of CHO with him ( An apple or orange juice, or a piece of
fruit).

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Energy Expenditure
during
Physical Activity!

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 Energy Cost of Physical Activity
(kilocalorie/kg. min)
Activity Calorei
Brisk walking 0.07
Running (7.5 min per km) 0.13
Running (5 min per km) 0.208
Swimming 0.162
Rope skipping (70/min) 0.162
Rope skipping (80/min) 0.165
Badminton 0.097
Tennis 0.109
Squash 0.212
Basketball 0.138
McArdle, et., 1991
 Energy Cost of Physical Activity
(MET)
Activity MET
Walking (slow) 2.5
Walking (Brisk) 4
Running (7.5 min per km) 8
Swimming 6
Rope skipping (slow) 8
Weight training 6
Badminton 4.5
Tennis (single) 8
Squash 12
Basketball 8
Ainsworth, et., 2000
 How to Calculate
Energy Expenditure
during Brisk Walking!

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Energy Expenditure during Brisk Walking

= 0.07 k. calorie per kg of body weight /

min.

An Example:
a person weighing 76 kg would expend:
0.07 X 76 = 5.3 k. calorie per min.

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Energy Expenditure during Brisk Walking

 If he has to expend 1200 k. calories per week.

How much time he should walk per week?

 1200 / 5.3 = 226.4 min.

= 45 min / 5 days per week, or
= 57 min / 4 days per week.

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Case Studies

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 Case Study 1 (Q)

An obese sedentary women, her age = 55 yrs,

weight = 80 kg, height = 152 cm.
Has type 2 diabetes for 6 years, and BP under
control with medication. Otherwise she is OK.
Prescribe diet and physical activity to reduce her
weight as well as to control her diabetes and
hypertension, targeting energy expenditure with
exercise of 1600 K. calories per week?
Assuming a target body wt. of 60 kg, what is her
daily energy needs?
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 Case Study 1 (A)

BMI = 80/ (1.52 * 1.52) = 34.6 kg/m2

Walking: 0.07 K. calorie/kg. min.

Energy cost of walking = 80 * 0.07 = 5.6 k cal. min.

Time needed to expend 1600 k. cal. Per week =

1600/ 5.6 = 285.7 minutes;
285.7/5 days = 57.1 min.
OR approx. 1 hour a day for 5 days per week

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