diabetes is a group of disorders that are associated with high blood sugar levels. Noninsulin-dependent diabetes mellitus (N IDDM , or ty pe …
Vol 1 No 4 July 2003
An
ICAA
Publication in five people in this age group–have the disease, according to the American Diabetes Association ADA And the number of recognized new cases among older adults is growing For instance, in the years 198094, new cases among women in this age group rose from 97,000 to 181,000, an increase of 457 Today, about 45 million women ages 60-plus have diabetes, with 12 million unaware they have the disease In addition, approximately one million people are diagnosed with diabetes annually That number will soar in the coming decades According to a study by CDC, [t]he number of Americans with diagnosed diabetes is projected to increase 165, from 11 million in 2000 prevalence of 40 to 29 million in 2050 prevalence of 72 The largest percent increase will be among people ages 75-plus years Minority racial and ethnic populations are particularly at risk of developing the disease
Table of contents
Exercise for people with type 2 diabetes pg 1 Preventing type 2 diabetes pg 10 What do I tell my client pg 12 Client handout: choosing shoes: a guide for people with diabetes pg 13 Hyperthermia: a hot weather hazard for older people pg 15 Comment pg 17
Contents
copyright 2003 by the International Council on Active Aging All rights reserved
Exercise for people with type 2 diabetes
by Shirley Archer, JD, MA More than 17 million Americans suffer from diabetes, a metabolic disease in which the body has difficulty converting food into fuel People with diabetes have a shortage of insulin or a decreased ability to use insulin, a hormone that allows glucose sugar to enter cells and be converted to energy, explains a publication by the Centers for Disease Control and Prevention CDC One in three people with diabetes, or 59 million people, do not know they have the disease, increasing the risk for serious complications Diabetes can lead to heart disease, stroke, vision loss or eye damage, kidney disease and kidney failure, nerve damage, amputations, frozen shoulder and gum disease Diabetes also raises the risk threefold of dying from complications related to influenza or pneumonia In America, diabetes is currently the sixth leading cause of death and a leading cause of blindness and amputations Among adults ages 65 and older, diabetes is one of the most common chronic health conditions Seven million individuals–one
Different types of
diabetes
Although several categories of diabetes exist, the disease has two main types In type 1, or insulin-dependent diabetes mellitus, the body is either completely unable to produce insulin, which controls blood glucose levels, or is able to produce such a tiny amount that insulin injections are necessary In type 2 diabetes, also known as non-insulin-dependent diabetes mellitus, the body cannot produce enough insulin or the cells cannot absorb the insulin This results in high levels of glucose remaining in the bloodstream Type 2 diabetes affects 9095 of people with the disease, most commonly after age 40, and is linked with unhealthy lifestyle behaviors, such as obesity and physical inactivity In fact, almost 90 of people with
Continued on page 2
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
1
Continued from page 1
type 2 diabetes are overweight or obese, according to ADA This article focuses on exercise program needs for people with type 2 diabetes Those with type 1 diabetes have specialized needs beyond the scope of this article References to people with diabetes in this article include only those with the type 2 disease
decrease risk factors for
cardiovascular disease, and result in improved glucose tolerance and insulin sensitivity, according to ACSM Resistance training can also increase the resting metabolic rate to assist in weight control Although not individually studied in relationship with diabetes, range of motion exercise contributes to an individuals ease of movement and functional ability In addition, individuals with diabetes have a much higher likelihood of adhesive capsulitis, more commonly known as frozen shoulder, than the general population And they are less likely to make a full recovery–even with physical therapy About 20 of people with type 2 diabetes are affected by frozen shoulder and may face a permanent loss of as much as 50 of shoulder mobility The first line of treatment for this condition is usually stretching and moving the shoulder in physical therapy, plus exercise Regular exercise also has important emotional health benefits for those living with diabetes, says ACSM, including reduced stress, heightened psychological well-being and enhanced quality of life
What kinds of exercise and why?
Approximately 60 of people with diabetes have hypertension high blood pressure, according to ADA, while
nearly all have one or more lipid abnormalities Regular exercise helps individuals with diabetes manage these chronic conditions or lessens the likelihood of developing coronary artery disease, hypertension and hyperlipidemia high cholesterol While the management of blood sugar has always been and remains a cornerstone of diabetes care, says ADA, diabetes requires a comprehensive program that includes management of blood glucose, management of blood pressure and management of cholesterol Cardiovascular exercise is a key component in helping people with diabetes to manage blood sugar levels and improve the bodys ability to use insulin This exercise helps maintain healthy blood sugar levels by burning fuels and by helping people to achieve and maintain a healthy weight and body composition However, improvements in glucose tolerance and insulin sensitivity are usually short-lived, deterioriating within three days of the individuals last workout This factor makes regular aerobic exercise vital The American College of Sports Medicines ACSM position stand on exercise and type 2 diabetes cautions that participants in some studies have had no improvement in glucose control from mild to
moderate aerobic exercise In addition, adults ages 55 and older may not show the same exerciseinduced blood glucose changes as usually occur in younger counterparts Resistance training has the potential to improve muscle strength and endurance, enhance flexibility and body composition,
Exercise risks
People with diabetes may be on a therapeutic program that includes medications, nutritional guidelines and regular exercise Exercise helps decrease blood glucose concentrations, potentially reducing or eliminating insulin doses Because of the critical importance of managing blood glucose levels, clients with diabetes must be under effective therapeutic care before beginning an exercise program And they must understand how activity and medications affect their blood glucose levels for a program to be safe and effective for them When training someone with diabetes, health and wellness professionals should develop an understanding of the condition, exercise needs and precautions to minimize risks of injury For example, ADA cautions people with any type of diabetes about exercising if their fasting blood glucose is more than 300 mg/dl
Continued on page
3
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
2
Continued from page 2
In another example, foot problems may require some individuals with diabetes to do non-weight bearing activities, ie swimming, water aerobics or cycling Damage caused by peripheral neuropathy, which affects the nerves to the toes, feet, legs, hands and arms, may also necessitate non-weight bearing exercise Thats because peripheral neuropathy results in a loss of feeling in the extremities and can cause foot deformities, gait changes and balance problems Descriptions of common diabetes-related conditions are available online from the National Diabetes Information Clearinghouse See Resources on page 9 for more information In particular, professionals working with clients who have type 2 diabetes need to know the symptoms of hypoglycemia and emergency procedures to follow, if necessary Hypoglycemia The greatest exercise risk to people with diabetes is hypoglycemia or low blood sugar levels Hypoglycemia can lead to a life-threatening loss of consciousness According to ADAs exercise safety tips, people with type 2 diabetes controlled by meal planning and exercise usually dont have
problems with low blood glucose However, those who take insulin or oral diabetes medicine, in particular sulfonylureas, may have low blood sugar levels both during and after exercise For more information, see Medicines for people with type 2 diabetes on page 8
An individuals risk of developing low blood glucose is greatest after high-intensity or long duration exercise But this reaction can take place even 12 or more hours after a workout, says ADA To help prevent hypoglycemia, a person must time medications carefully eg ACSM recommends injecting insulin at least one hour before exercise, ensure adequate food intake see below and monitor blood glucose levels before and after exercise, as well as during longer exercise sessions or when trying a new activity Health and wellness professionals should learn to recognize the warning signs of hypoglycemia and monitor clients with diabetes carefully see Hypoglycemia: signs and symptoms on page 4 for a list If someone becomes hypoglycemic, he or she needs a rapidly absorbed sugar source immediately, ie a half-cup of fruit juice or regular soda, two teaspoons of sugar or raisins, or six jelly beans or hard candy If the individual loses
consciousness or if the persons symptoms do not respond to rest and sugar, the professional should contact emergency services right away Food intake Since exercise burns fuel, people with diabetes need to monitor food intake carefully in relationship to increased activity ADA advises individuals with diabetes to exercise from 13 hours after eating a meal One hour of exercise generally requires 15 additional grams of
Continued on page 5
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
3
Continued from page 3
carbohydrates, which clients should consume before or after exercise, depending on their individual condition and needs If exercise is vigorous or longer than one hour, an additional 1530 grams are recommended for each additional hour [Ed a single slice of bread contains 15 grams of carbohydrates, as does a half-cup of fruit juice Single doses of Glutose gels from Paddock Laboratories also contain 15 grams of carbohydrates] People with diabetes should keep a source of rapidly acting carbohydrate easily available during exercise and tell others where this source is located Health and wellness professionals should also keep hard candy or other sources of
simple sugar available for emergency purposes Dehydration High blood sugar levels can increase urination, contributing to dehydration In addition, diabetic complications such as autonomic neuropathy, which affects the nerves serving internal organs and regulating blood pressure, blood glucose and perspiration, may impair an individuals sweating response, increasing the risk of heat-related illness Hyperthermia: a hot weather hazard for older people on page 15 tells how to recognize and prevent heat-related illness Professionals should encourage participants with diabetes to drink fluids before, during and after exercise, especially in warmer environments ADA recommends that people with the disease drink at least a half liter of fluid two hours before exercise During exercise, plain water is usually sufficient for sessions of one hour or less, according to ACSM For workouts lasting longer than one hour, water and extra carbohydrates are needed People with diabetes will absorb beverages with a 68 carbohydrate solution, such as Gatorade, more easily than soft drinks or fruit juices, which are typically 1314 carbohydrate solutions Foot or lower leg injuries Clients with diabetes,
especially those with more severe conditions, may have nerve damage or circulatory disorders, such as peripheral
Continued on page 6
Hypoglycemia: signs and symptoms
Watch for the following warning signs and symptoms of hypoglycemia, or low blood sugar levels, in clients with diabetes: Extreme fatigue Excessive sweating Headache Trembling or shakiness Weakness Slurred speech Poor coordination Feeling faint Loss of consciousness Seizure Pale, moist skin Full, rapid pulse Tremors Elevated blood pressure Nervousness Palpitations Excessive hunger Irritability and other abrupt mood changes Impaired concentration and attentiveness Mental confusion Drowsiness Be prepared to provide a sugar source to a client immediately if he or she starts experiencing hypoglycemia Rapidly absorbed carbohydrates include a halfcup of fruit juice or regular soda, two teaspoons of sugar or raisins, or six jelly beans or hard candy Contact emergency services right away if the individual loses consciousness or if his or her symptoms do not respond to rest and sugar Reference
Gordon, NF Diabetes Your Complete Exercise Guide Cooper Clinic and Research Institute Fitness Series 1993 Champaign IL: Human
Kinetics
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
5
Continued from page 5
vascular disease As these individuals may have impaired blood flow to the extremities, they require extra protection of the feet to prevent bruising or injury Health and wellness professionals should advise clients to wear appropriate athletic footwear, and to wash and dry their feet thoroughly after class and check for sores Petroleum jelly may help to decrease friction on specific areas If a client has an open sore that is not healing, he or she should consult a healthcare provider immediately When not treated promptly, an infection can spread to the bone, resulting in amputation Fitness equipment that may impair circulation should be avoided, ie bands or buoyancy equipment on legs or feet in water exercise Aquatic instructors should cue participants to keep their legs moving during class by jogging or kicking to avoid blood pooling in the legs Inadequate blood supply may cause participants to be more prone to pain, aching or cramping during exercise Instructors should encourage exercisers to rest for about two minutes if cramping occurs during a workout
heart rate and
blood pressure should be accommodated Generally speaking, however, people with diabetes benefit most from aerobic exercise and resistance training Include cardiovascular training ACSM strongly recommends that individuals with type 2 diabetes expend a minimum cumulative total of 1,000 kcals per week in aerobic activity This includes at least three nonconsecutive days and up to five sessions per week Ideally, exercise sessions should last a minimum of 30 minutes Use Ratings of Perceived Exertion RPE to monitor intensity Low- to moderate-intensity aerobic training is recommended to enhance exercise adherence and to reduce the risk of injury, especially foot trauma However, conditions such as autonomic neuropathy affect an individuals heart rate response to exercise, so the best method to determine intensity is the Borg RPE scale [Ed the June 2003 issue of Functional U TM includes the Borg Scale and instructions for its use] Progress gradually People with type 2 diabetes often find endurance exercise uncomfortable Interestingly, individuals with this disease category have an increased number of type II or fast twitch muscle fibers, a low percentage of type I or slow twitch muscle
fibers and low capillary density These muscle fiber differences may affect both tolerance for aerobic activity and make the intensity of exercise at the anaerobic threshold lower When designing a class structure, health and wellness professionals should plan a longer warm-up, increase exercise intensity gradually and provide a longer cooldown for participants Keeping exercise intensity at a low enough level to be comfortable is particularly important for beginning exercisers ACSM recommends exercise at RPE 1012 during the initial stages of training Progressing to higher levels should be undertaken gradually as tolerance improves Given that older age and obesity are common elements of type 2 diabetes,
Continued on page 7
Exercise program recommendations
Health and wellness professionals should ensure that clients have a thorough medical evaluation and obtain clearance to exercise before beginning any program or increasing intensity levels They should then review this form for specific guidelines ACSM also recommends that people with diabetes ages 35 and above have a stress test to assess cardiovascular and respiratory systems As diabetes is a major risk factor for cardiovascular
disease, certain individuals may have advanced cardiovascular complications, which will require exercise modifications Physical activity for people with autonomic neuropathy should also be approached with caution, according to ACSM, which stresses the need for medical clearance for these individuals For people with this condition, [p]hysical activity should focus on lowlevel daily activities, where mild changes in
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
6
Continued from page 6
states ACSM, a longer period of time may be necessary for the older adult and/or obese person to adapt to a recommended physical activity program Incorporate resistance training Resistance training at least two days a week to improve muscular strength and endurance and to improve body composition is also recommended by ACSM In addition to improving muscular fitness, resistance training can enhance the muscles ability to absorb and store glucose However, the intensity of a strength training program will need to vary depending on individual conditions Health and wellness professionals must ensure their clients have been medically cleared specifically for resistance training
before they begin any program, as this type of activity may not be recommended for some individualsFor example, ACSM advises caution with people who have advanced cardiovascular or retinal complications And while those with nephropathy kidney disease or diabetic retinopathy in which blood vessels in the eye are damaged may benefit from low-intensity exercise, they should avoid any activity that results in a rise in systolic blood pressure to 180200 mmHg, including high-intensity strength training In general, lower intensity resistance training, such as 1215 repetitions to fatigue, is recommended for participants with diabetes Circuit training that includes short
cardiovascular bouts mixed with strength training exercises may be particularly beneficial and fun Modify as necessary for coexisting conditions For people with more severe diabetes or more advanced diabetic complications, ACSM suggests considering modifications in resistance training such as lowering the intensity of lifting, preventing exercise to the point of exhaustion and eliminating the amount of sustained gripping or isometric contractions The valsalva maneuver should be avoided, as should the use of handheld
equipment for long periods of time In the book Essentials of Strength Training and Conditioning, Thomas R Baechle and Roger W Earle describe the valsalva maneuver as airway straining during forced exhalation against a closed glottis Health and wellness professionals should cue frequently to remind participants to breathe and maintain a relaxed grip when using equipment Other activities to avoid include those that cause any large or sudden increases in blood pressure, such as repetitive overhead arm movements, suddenly lowering the head or excessive jarring movements, ie repetitious jumps or hops
Encourage exercise for health
Consistent moderate exercise provides tremendous health benefits for people with type 2 diabetes However, physical activity is often underused as a source of therapeutic treatment The health or wellness professionals knowledge of the particular concerns of people with diabetes and sensitivity to their special exercise program needs can provide valuable support Encouraging the clients adherence to a regular program of activity is much more important than undertaking an aggressive training program The professionals understanding, support, expertise and continued
motivation may be key to keeping clients with diabetes active 
, healthy and returning regularly to enjoy a higher quality of life
Continued on page 8
Did you know?
People with peripheral vascular disease which causes poor circulation to the legs and feet, to which people with diabetes are predisposed, should avoid cross-legged positions when stretching Elizabeth Best-Martini and Kim A Botenhagen DiGenova, authors, Exercise for Frail Elders 2003 Champaign IL: Human Kinetics
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
7
Continued from page 7
Shirley Archer, JD, MA, is author of the Pilates Deck and the Everything Weight Training Book Shes a health and wellness educator, award-winning author, chair of the IDEA Water Fitness Committee and an international presenter Contact Shirley regarding workshops or her books at wwwshirleyarchercom References
Albright, A; Franz, M; et al 2000 ACSM Position Stand: Exercise and Type 2 Diabetes Medicine Science in Sports Exercise 2000;32:134560 American Diabetes Association Healthy Living: Exercise: Getting Started: Safety Tips wwwdiabetesorg/main/health/exercise/safety/ 25waysjsp, accessed July 8, 2003 American
Diabetes Association Make the Link for the Health Care Professional wwwdiabetesorg/ main/info/link_healthprofjsp, accessed July 8, 2003 American Diabetes Association Type 2 Diabetes Diabetes Complications and Related Concerns wwwdiabetesorg/main/type2/complications/ defaultjsp, accessed July 8, 2003 American Diabetes Association Weight Loss Matters: American Diabetes Association Obesity Initiative wwwdiabetesorg/main/health/weightloss/defaultjsp, accessed July 8, 2003 Anthony, L 1995 Diabetes and Exercise IDEA Personal Trainer, June 1995: pp 1518 Archer, S 2002 The Everything Weight Training Book Holbrook MA: Adams Media Corporation Archer, S, coauthor; Sanders, M, ed 1999 YMCA Water Fitness for Health Champaign IL: Human Kinetics Baechle, TR and Earle, RW, eds 2000 Essentials of Strength Training and Conditioning Champaign IL: Human Kinetics Boulé, NG; Haddad, E; et al 2001 Effects of Exercise on Glycemic Control and Body Mass in Type 2 Diabetes Mellitus: A Meta-analysis of Controlled Clinical Trials Journal of the American Medical Association 2001;286:12181227 Boyle, JP; et al Projection of Diabetes Burden through 2050 Diabetes Care 2001;24:19361940 Centers for Disease Control
and Prevention 2002 Diabetes: Disabling, Deadly, and on the Rise At A Glance 2003 Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention wwwcdcgov/nccdphp/aag/aag_ ddthtm, accessed July 8, 2003
Centers for Disease Control and Prevention 2001 Diabetes and Womens Health Across the Life Stages: A Public Health Perspective: The Elder Years 65 Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention wwwcdcgov/diabetes/pubs/ women/indexhtm, accessed July 8, 2003 Centers for Disease Control and Prevention 2002 National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2000 Atlanta GA: US Department of Health and Human Services, Centers for Disease Control and Prevention wwwdiabetesorg/main/ info/facts/facts_natljsp, accessed July 8, 2003 Durstine, LJ Sr, ed; et al 1997 ACSMs Exercise Management for Persons with Chronic Diseases and Disabilities Champaign IL: Human Kinetics Franklin, BA Sr, ed; et al 2000 ACSMs Guidelines for Exercise Testing and Prescription, Sixth Edition Baltimore MD: Lippincott, Williams Wilkins Lepore, M; Gayle, GW; et al 1998Adapted
Aquatics Programming Champaign IL: Human Kinetics National Institute of Diabetes and Digestive and Kidney Diseases Diabetic Neuropathies: The Nerve Damage of Diabeteswwwdiabetesniddk nihgov/dm/pubs/neuropathies/indexhtm, accessed July 8, 2003 Zinman, B; Ruderman, N; et al 2002 American Diabetes Association: Clinical Practice Recommendations 2002: Position Statement, Diabetes Mellitus and Exercise Diabetes Care 2002;25s1:S64S68 Zinman, B; Ruderman, N; et al 1998 ACSM and American Diabetes Association Joint Position Statement: Diabetes Mellitus and Exercise Medicine Science in Sports Exercise 1998;29:ivi
Medicines for people with type 2 diabetes
Visit the National Diabetes Information Clearinghouse website at wwwniddknihgov/health/diabetes/ pubs/med/specifichtmpills for a list of specific diabetes medications
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
8
Resources
Print resources
Durstine, JL and Moore, GE, eds 2003 ACSMs Exercise Management for Persons with Chronic Diseases and Disabilities Second Edition Champaign IL: Human Kinetics Gordon, NF, MD 1993 Diabetes: Your Complete Exercise Guide Cooper Clinic and Research Institute Fitness Series
Champaign IL: Human Kinetics Sanders, ME, ed 2000YMCA Water Fitness for Health Champaign IL: Human Kinetics and the YMCA of the USA
HealthTalk Diabetes Education Network wwwhealthtalkcom/den/indexhtml National Diabetes Education Program wwwndepnihgov National Diabetes Information Clearinghouse wwwdiabetesniddknihgov/ Check out this site for details about complications related to diabetes, plus the excellent Prevent Diabetes Problems brochure series Small Steps Big Rewards HHS/NDEP Diabetes Prevention Campaign wwwndepnihgov/get-info/ dpihtm Your Game Plan for Preventing Type 2 Diabetes Health Care Providers Toolkit http://ndepnihgov/materials/pubs/DPP/ GPToolkitpdf Your Game Plan for Preventing Type 2 Diabetes Information for patients http://ndepnihgov/materials/pubs/DPP/ gameplanpdf These resources help with initiating a lifestyle intervention programThe Health Care Providers Toolkit includes copierready versions of client handouts Diabetes Prevention Program wwwbscgwuedu/dppalshtmlvdoc Manuals and protocols for lifestyle modification strategies from this national program can be used for educational and research purposes
Online resources
American Diabetes Association
wwwdiabetesorg Canadian Diabetes Association wwwdiabetesca Centers for Disease Control and Prevention wwwcdcgov/diabetes Diabetes Exercise and Sports Association wwwdiabetes-exerciseorg
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
9
With prediabetes, an individuals blood sugar levels are higher than normal, but not high enough for a diabetes diagnosis Doctors commonly refer to this condition as impaired glucose tolerance or impaired fasting glucose Research supported by the US Department of Health and Human Services HHS shows that most individuals with prediabetes will likely develop type 2 diabetes within 10 years unless they make some changes to their lifestyle In 2002, a panel of experts convened by HHS and ADA stated that intervention in prediabetes is critical for three reasons: First, simply having blood glucose levels in the prediabetes range puts a person at a 50 greater likelihood of having a heart attack or stroke; Second, research shows that the development of type 2 diabetes can be delayed or prevented through modest lifestyle improvements; and Third, for many people, modest lifestyle improvements can turn back the clock and return elevated
blood glucose levels to the normal range
Preventing type 2 diabetes
Today, diabetes affects 17 million Americans In 2002, the direct and indirect costs of the disease totaled 132 billion, or one out of every ten healthcare dollars spent in the United States, says the American Diabetes Association ADA Yet the healthcare burden and personal costs related to diabetes can largely be prevented through lifestyle modification A study published in the New England Journal of Medicine in 2001 showed that more than 90 of type 2 diabetes is preventable and relates to unhealthy habits and behaviors Hu et al, 2001The scientists found that overweight or obesity was by far the most important predictor of the disease Of the 17 million individuals living with diabetes in the US, 16 million have the type 2 disease A further 16 million adults ages 4074 have prediabetes, says the National Diabetes Education Program NDEP, a federally sponsored public/private initiative
The panel analyzed several major studies that evaluated strategies to prevent type 2 diabetes These studies included the 19982001Diabetes Prevention Program, a clinical trial of more than 3,000 people, which was sponsored by the
National Institutes of Health This multi-site program found that diet and exercise resulting in a weight loss of 57 lowered the incidence of type 2 diabetes in study participants by 58 According to NDEP, this intervention was particularly successful with adults ages 60 and older, reducing their development of diabetes by 71 Participants in the program lost weight by cutting fat and calories in their diet and by exercising– mostly walking–at least 30 minutes a day, 5 days a week NDEP has launched a national awareness campaign called Small Steps Big Rewards Prevent Type 2 Diabetes, which aims to reach people with prediabetes Based on the Diabetes Prevention Program, the campaigns GAME PLAN program Goals, Accountability, Monitoring and Effectiveness:
Continued on page 11
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
10
Continued from page 10
Prevention through a Lifestyle of Activity and Nutrition provides tools to help people make lifestyle changesVisit NDEPs website at http://ndepnihgov/get-info/dpihtm or call 800-438-5383 for details or educational materials Check out the GAME PLAN Toolkit for Health Care Providers for information on how to talk to
clients about the program, plus copier-ready client handouts NDEP also partners with organizations concerned about diabetes and the health status of their constituents To learn more, check out the NDEP fact sheet at http://ndepnihgov/materials/pubs/NDEPfactsheethtm Or join NDEPs partnership network by filling out the online form at http://ndepnihgov/partner/howhtm References
American Diabetes Association Direct and Indirect Costs of Diabetes in the United States wwwdiabetesorg/main/info/facts/facts_costsjsp, accessed July 9, 2003 American Diabetes Association and US Department of Health and Human Services Press release: HHS, ADA warn Americans of pre-diabetes, encourage people to take healthy steps to reduce risks: updated statistics show 17 million with diabetes, 16 million more with pre-diabetes March 27, 2002 wwwdiabetesorg/main/community/info_news/ prediabetesreleasejsp, accessed July 10, 2003 Hogan, P; Dall,T; Nikolov, P 2003 American Diabetes Association: Economic Costs of Diabetes in the US in 2002 Diabetes Care 2003;26:917932 Hu, FB: et al 2001 Diet, Lifestyle, and the Risk of Type 2 Diabetes Mellitus in Women New England Journal of Medicine 2001;345:790797 National
Diabetes Education Program HHS/NDEP Diabetes Prevention Campaign http://ndepnihgov/ get-info/dpihtm, accessed July 9, 2003 National Diabetes Education Program NDEP Fact Sheet http://ndepnihgov/materials/pubs/NDEPfactsheethtm, accessed July 9, 2003
Risk factors for diabetes Older than 45 Overweight Close family member with diabetes Gestational diabetes Gave birth to 9 lbs-plus baby African-American, Hispanic or Latino, Asian-American or Pacific Islander, or American-Indian High blood pressure High cholesterol or other abnormal blood fats Inactive Abnormal blood glucose test Source: National Diabetes Education Program
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
11
What do I tell my client
The scenario
An older woman just diagnosed with type 2 diabetes is preparing to start an exercise program She wants to know how exercise will help her, plus exercise dos and donts
or just starting an activity Ask your client whether she takes beta-blockers, which can mask symptoms of low blood sugar Advise her to keep a sugar source handy in case she becomes hypoglycemic If your client has autonomic neuropathy, recommend low-level daily activities that cause mild
changes in heart rate and blood pressure With nerve damage, she should avoid exercising in hot environments Cold environments are also problematic if your client has peripheral vascular disease loss of circulation If your client has poor circulation, advise her to avoid cross-legged stretches and to select comfortable shoes that fit well Emphasize attention to footwear and foot care, and caution your client to visit a healthcare provider at the earliest sign of a problem If your client has nerve damage, she may have weak muscles and poor reflexes in her feet Her balance and gait may be affected Suggest non-weight bearing activities, or consider alternating weight bearing with non-weight bearing exercise Recommend light weight training RPE of 1011 if your client has normal blood pressure, unless contraindicated If your client has eye or kidney disease, caution her against exercise that raises her systolic blood pressure to 180200 mmHg, ie arms frequently overhead If your client has cardiovascular complications, tell her to avoid arms overhead exercise Also, suggest she check her blood pressure and pulse before and after exercise If your clients fasting blood glucose ever exceeds 300
mg/dl, advise her not to exercise until her blood sugar is under control or she visits her healthcare provider References
Albright, A; Franz, M; et al 2000 ACSM Position Stand: Exercise and Type 2 Diabetes Medicine Science in Sports Exercise 2000;32:134560 American Diabetes Association Healthy Living: Exercise: Getting Started: Safety Tips wwwdiabetes org/main/health/exercise/safety/25waysjsp, accessed July 8, 2003 Best-Martini, E and Botenhagen DiGenova, KA 2003 Exercise for Frail Elders Champaign IL: Human Kinetics
The facts
An eight-week circuit training program improved functional capacity, lean body mass, strength and glycemic control in subjects with type 2 diabetes Source: Diabetes Research and Clinical Practice 2002;56:115123 A review of research states that progressive resistance training PRT improves insulin sensitivity and glycemic control; increases muscle mass, strength, and endurance; and has positive effects on bone density, osteoarthritic symptoms, mobility impairment, self-efficacy, hypertension, and lipid profiles Source: Diabetes Care 2003;26:15801588 A study of more than 50,000 men ages 4075 years shows that physical activity reduces the risk for heart
attack and death in men with type 2 diabetes Diabetic men in the third highest of four categories of total physical activity reduced their risk of heart disease by 36 and death by 43 compared to those in the lowest category Source: Circulation 2003;107:24352439, 23922394
The solution
Ensure your client has medical clearance to exercise Check whether resistance training is specifically approved and note any cautions If your client relies on insulin, suggest she consult her healthcare provider about coordinating her exercise and insulin Urge your client to monitor her blood glucose levels to find out how exercise affects her blood sugar To prevent hypoglycemia, your client should check her blood glucose before and after exercise, plus monitor levels for at least 12 hours after exercise Checking blood glucose during workouts is usually advised for people who take insulin or oral diabetes medicines, as well as for individuals doing long workouts
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
12
Choosing shoes: a guide for people with diabetes
Older adults have a lot to think about when it comes to being active–including their feet Deciding which shoes to
buy is important for men and women who have diabetes What advice do the experts offer? 1 Fit Timothy Kalla, a clinical instructor with the University of British Columbia, says a professional fit is the most important shoe feature for people with diabetes There are four main risk factors for foot problems for these individuals: Previous problems; Loss of circulation; Loss of feeling; and Foot deformity hammer toes, bunions, calluses, limitation of motion, etc People are more likely to have foot problems when they have more risk factors So the person who fits the shoe must understand the effect diabetes has on the feet 2 Material Footwear expert Phil Moore says shoes must be smooth on the inside Its also better to have shoes with seamless toe boxes, often with uppers made of heat moldable material or deerskin as with orthopedic shoes Running shoes have more seams than is ideal, but the mesh often stretches to make room for problem areas 3 Size Kalla says loss of feeling is the greatest risk factor for foot trouble in people with diabetes He says that people with feeling loss typically buy shoes that are too small, because they can feel the shoe These people will complain that their
shoes are too big when fitted with the right size But wearing shoes that are wide and long enough can help prevent toenail injuries and reduce pain in the front of the feet, says Moore 4 Accommodation Deformed areas are prone to rubbing, says Kalla For instance, a hammer toe may rub on the seam of a shoe A pair of extra depth or high volume shoes without seams and with a soft upper is vital for someone with loss of feeling and foot deformity 5 Protection The skin around the foot thins with age, says Moore, so active older adults need shoes with more padding They also
Continued on next page
Client handout
Answer these questions before you shop Footwear expert Phil Moore says there are four key questions you should answer before trying on athletic shoes: What are you doing in the shoe? The shoes features must match the activity What have you worn in the past? If it aint broke, dont fix it Do you have any special needs? Make sure the shoes features work well for you Consider former injuries, orthotics, bunions, whether your feet roll in or out, etc Matching a shoe to your needs is often the key to a good fit and painfree activity What size and width are you? All sizes are not the
same, so try on shoes until you find the right size in the right model model
International Council on Active Aging TM
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
13
Continued from previous page
Client handout
need socks that remove moisture from the feet to cut down on blistersWalking shoes usually dont have the support, fit or cushioning of a running shoe According to Kalla, people who have diabetes and feeling loss often need cushioned orthotics or supports to protect their feet Individuals must keep orthotics in mind when choosing and fitting a shoe 6 Grip Loss of balance often goes with feeling loss Shoes with low soles and a wide, stable heel can help, says Kalla Sometimes heels need to be flared outwards for more support The shoes sole is also important, especially in wet climates Many therapeutic shoes have slippery soles, which are risky for people with feeling and balance loss Moore says that athletic shoes offer good gripping outer soles On the other
hand, the outer soles of orthopedic footwear often have no tread pattern This smooth bottom may be good for people who shuffle when they walk and trip easily in shoes with thick soles, but it
is risky in wet conditions A fall may be worse than the original foot problem 7 Support Dr Jack E Taunton, codirector of the Allan McGavin Sports Medicine Centre at the University of British Columbia, says good shoes with extra arch support, heel control and additional heel lifts are important for the older person, as the aging foot loses strength and flexibility Functional UTMthanks Phil Moore for providing this material Moore has written the Shoe Update, a review of footwear for the healthcare industry, since 1984 He also is coowner of LadySport Ltd 1983, a retail chain that sells athletic shoes and fitness gear You can email Phil questions about footwear at info@ladysportca
Your company name and logo here
International Council on Active Aging TM
Disclaimer: This handout is not intended to replace a one-on-one relationship with a qualified healthcare professional and is not intended as medical advice It is intended as a sharing of knowledge and information from research The ICAA encourages you to make your own health and business decisions based upon your research and in partnership with a qualified
professional
wwwicaacc
C
h
a
n
g
i
n
g
t
h
e
W
a
y
W
e
A
g
e
TM
14
Source:altfutures.com
