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ouch potato. Does this term aptly describe you or the individuals that you care for during your daily practice? If so, then do either of you carry extra, unwanted weight? Asking these two questions can be a lifesaver as well as lead to the prevention of the myriad of complications that are associated with diabetes. A recent study by the Harvard School of Public Health found that sedentary behaviors, particularly watching television, are related to the development of obesity and type 2 diabetes.1 In contrast, light to moderate activity was related to significantly lower risk for developing these all too common disorders or for preventing/delaying the onset of long-term complications.
       So what should we as healthcare providers do to assist individuals in the fight to prevent or reverse obesity and the complications of type 2 diabetes? Educate, support, and get our clients moving! Another recent study by researchers from the University of Glasgow, Scotland,2 found that the combined use of motivational strategies and cognitive behavioral therapy during the initiation of an exercise program resulted in improved outcomes. Individuals that received these interventions throughout their exercise program had greater improvement in blood pressures and decreased body mass index (BMI). They also exhibited better adherence to the exercise program.
       So, how do we get started? It is imperative that individuals with type 2 diabetes be evaluated by a physician prior to the initiation of an exercise program, particularly elderly individuals or anyone with long-standing disease. Diabetes is associated with both macrovascular and microvascular disease. As such, individuals should be evaluated for macrovascular disease including coronary artery and peripheral vascular disease as well as for the presence of microvascular disease (proliferative retinopathy and nephropathy). Individuals with suspected or known coronary artery disease should have an exercise stress test with an assessment of ischemic response to exercise.3 This test will often include evaluation of left ventricular systolic function at rest and during exercise. The physician should also determine if cardiac autonomic neuropathy (CAN) is present. CAN is associated with sudden death and silent myocardial ischemia. Individuals with CAN are more likely to develop either hypotension or hypertension postexercise. Signs of CAN include resting tachycardia (>100 beats/min) and orthostasis (precipitous decline in blood pressure > 20mmHg with standing).
       Presence of peripheral vascular disease (intermittent claudication, cold feet, decreased or absent pulses, hair and subcutaneous fat loss) should also be determined. If the disease has not progressed past the moderate stage with no resting pain or ulceration present, graded exercise may be initiated using timed walk or treadmill training exercises.3 Likewise, individuals should also be screened for retinopathy and nephropathy. Individuals with active proliferative retinopathy should not participate in any activity that causes straining or jarring, as this may precipitate vitreous hemorrhage or retinal detachment. With overt nephropathy, mild to moderate exercise can be performed cautiously, but blood pressure should be monitored.
       Another area that requires active monitoring in an individual with diabetes during exercise is the feet, especially if peripheral neuropathy is present.4 If an individual has lost protective sensation in the feet, weight-bearing exercise should be limited to prevent injury. Weight-bearing exercise may induce ulceration or stress fracture in the individual with peripheral neuropathy. Activities that are less stressful to the tissues of the feet include aquatic exercise and the recumbent cycle. As with normal daily gait activities, the use of special socks that utilize silica gel or air to decrease pressure and shear on the plantar surface of the feet and appropriate footwear are recommended during land-based exercise. Postexercise, it is also important the individual’s feet be examined for any injury and be cleaned and dried.
       What is the next step? Determining the individual’s fitness level is the first step to prescribing an exercise program. According to the American Diabetes Association (ADA),4 everyone with diabetes including the elderly can exercise. The ADA position statement on physical activity/exercise and diabetes states “middle-aged and older adults should be encouraged to be physically active.”4 Current recommendations for exercise include both aerobic activity and strength training (moderate weight training with light weights and high repetitions). Aerobic activity is known to have a positive effect on lowering blood glucose, and the American College of Sports Medicine (ACSM) recommends that individuals engage in 20 to 60 minutes of aerobic activity between three and five days a week.3 It is also recommended that individuals with type 2 diabetes work toward a greater total duration of exercise (approximately 1 hour/day). This greater duration of sustained aerobic activity is valuable in promoting fat loss and reducing obesity. These activities can be performed singly or in a group using a variety of modalities including music or water-based exercises.
       When preparing to exercise, it is important to begin with a warm-up session. Warm-up exercises should include 5 to 10 minutes of light aerobic activity to prepare the body followed by the same amount of time for stretching the muscles involved in the exercise program. Once the exercise activity has been completed, the individual should spend 5 to 10 minutes cooling down to bring the heart rate down to resting levels. Current recommendations from research and the ACSM indicate that the percent heart rate reserve (percent HRR, which is the difference between resting and maximum heart rate) be used to determine exercise intensity for individuals with diabetes.5 Individuals with diabetes and especially those with peripheral neuropathy should exercise at between 40 and 85 percent HRR.
       In conclusion, sedentary behaviors are linked to detrimental effects for individuals with type 2 diabetes. Daily exercise is beneficial for aging individuals with or without diabetes for numerous reasons—so get your clients moving! Physical therapists can assist you and your clients in initiating and establishing a safe exercise program. These programs can be delivered in groups or individualized to the person. Aquatic-based programs as well as music can make this a social and pleasant experience for everyone.