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Health and Wellness

Exercise Program for a Person with Diabetes

 

 Development and Implementation of an Exercise Program for

A Person with Diabetes

Paula McClellan-Hilbert

 exerciseprogramdiabete.htm

          Mr. Conner has come to our facility because his doctor has recently ordered he begin an exercise program.  He has an order for a series of tests, including a diagnostic exercise stress test.  Mr. Conner has type II diabetes and metabolic syndrome.

          An exercise and fitness plan for a person with diabetes is outlined.  Because of Mr. Conner’s history of inactivity, his program will be supervised. 

PAR-Q Rating

         Mr. Conner is a 40 year old man.  He answered "yes” to question 6 on the PAR-Q questionnaire.  His doctor has currently prescribed medication to lower his cholesterol and placed on a diuretic to lower his blood pressure.  Mr. Conner has led a very in-active lifestyle most of his life.

Health Status

In the Health style self test from the Thygerson & Larson, Fit to be Well Lab Manual, Mr. Conner scored a 10 in the smoking score; a 2 for the alcohol and other drugs score for handling stress; an 4 for the eating habit score; a 0 for Exercise/Fitness; a 0 for the stress management; and a 10 for safety.  In the drugs and alcohol score, he scored a 2 because of the medications he’s taking.  A score of 4 for eating habits is due to his dietary intake is high in fats and processed foods. In the Exercise/Fitness a score of 0 is because he does no exercise and lives a very sedentary lifestyle.  In the stress management self test, he only scored a 0, because he does not practice any type of relaxation methods nor does he feed his spirituality with church, except at holidays.  His body weight is 265 lbs., he is 5’ 9.5” tall and is approximately 103 lbs more than he should be for his height.   

General Medical History

           Mr. Conner answered the questions on the Health Status Questionnaire, form 3.2 from the Appendix in the Fitness Professional's Handbook.  General medical history is as follows:

Mr. Conner has recently been diagnosed with Type II diabetes and metabolic syndrome.  He has medical approval to begin exercise.  The overall exercise objective is to have Mr. Conner engage in regular exercise to improve is fitness and assist with his weight loss and glucose control.

Assessment Results on testing CRF

Cardio respiratory Fitness Results are as follows:

·         Resting heart rate:  110 beats per minute

·         Maximum Heart Rate should be = 220 – 40 = 180 MHR

·         Low End Target Zone should be = 180 x 70% = 126

·         High End Target Zone should be= 180 x 85% = 153

·         Height and weight = 69 ½” tall / 265 lbs, BMI = 40, Extremely obese

Mr. Conner’s cardio respiratory fitness is poor.  Resting heart rate should be at least 20 beats per minute less.  With exercise and diet, we should be able to get that resting heart beat down.

          VO2 max decreases about 1% per year in sedentary men and women because of a decrease in both maximal cardiac output and maximal oxygen extraction.  Endurance training increases VOmax results from gains in both maximal cardiac output and oxygen extraction in men but is due solely to an increase in oxygen extraction in women. 

Risk Factor Assessment - Risk Factors for Coronary Heart Disease

Risk Factors for Coronary Heart Disease are high because of abdominal obesity, high triglycerides, low HDL, elevated blood pressure and elevated fasting glucose.  The following are his readings:

Cholesterol 270 mg

Fasting glucose 132 mg / should be > 100 mg

LDL 190 mg / should be < 40 mg

Blood pressure 148/94 / should be > 130/>85

HDL 32 mg

VO2 Max 22 ml

High stress

Previously inactive

Supervised  evaluation of the ischemic response to exercise, ischemic threshold and the propensity to arrhythmia during exercise results in “No ischemia with GXT.”

Hypoglycemia (low blood sugar) is more prevalent in those with Type I diabetes rather than Type II diabetes during exercise, but Mr. Conner will be closely monitored to assure that hypoglycemia during exercise does not happen.  In patients with Type II diabetes, exercise may improve insulin sensitivity and assist in diminishing elevated blood glucose levels into normal range. 

Evaluations to be done of the Patient before Exercise:

·         Cardiovascular system due to diagnosis of Type II diabetes including an exercise stress test. 

·         Peripheral Arterial Disease (PAD) – based on signs and symptoms of intermittent claudicating, cold feet, decreased or absent pulse, atrophy of subcutaneous tissues and hair loss

·         Retinopathy – to follow the American Diabetes Association’s Clinical Practice Guidelines.

·         Nephropathy – Patients with overt nephropathy often have a reduced capacity for exercise which leads to self limitation in activity level.

·         Neuropathy; Peripheral – loss of protective sensation in the feet

·         Neuropathy; Autonomic – loss of individual’s exercise capacity and increase risk of adverse cardiovascular event during exercise.

(Zinman, B., Ruderman, P. etal; 1997)

Medications 

          Mr. Conner takes medication to lower his cholesterol and diuretic to lower blood pressure.  Monitoring of heart rate and blood pressure before, during and after exercise will alleviate concern over adverse reactions due to medication.

Physical Activity Patterns and Objectives

            Mr. Conner’s current physical activity pattern is sedentary.  Objectives include supervised aerobic activity as well as resistance training.

          During exercise, whole-body oxygen consumption may increase by as much as 20-fold, and even greater increases may occur in the working muscles.  To meet its energy needs under these circumstances, skeletal muscle uses, at a greatly increased rate, its own stores of glycogen and triglycerides, as well as free fatty acids derived from the breakdown of adipose tissue triglycerides and glucose released from the liver.  To preserve central nervous system function, blood glucose levels are remarkably well maintained during exercise.  (Zinman, B., Ruderman, P. etal; 1997).

          Regular exercise training on carbohydrate metabolism and insulin sensitivity utilizing exercise regimens at an intensity of 50-80% VO2 max 3-4 times a week for 30-60 minutes a session will improve glycemic control.

          The Insulin Resistance Syndrome is an important risk factor for premature coronary disease, particularly with concomitant hypertension, hyperinsulinemia, central obesity, and the overlap of metabolic abnormalities of hypertriglyceridemia, low HDL, altered LDL, and elevated FFA. 

          Regular exercise has consistently been shown to be effective in reducing levels of triglyceride-rich very low density lipoprotein.

          There is evidence linking insulin resistance to hypertension, and data suggests that exercise many enhance weight loss and in particular, weight management when used with an appropriate calorie controlled meal plan.

          Exercise, along with a diet plan may be useful in preventing or delaying onset of Type II diabetes.  (Zinman, B., Ruderman, P. etal; 1997)

Health and Lifestyle Behaviors

          Adherence rates must be acceptable and exercise will be supervised with frequent follow up assessments.  Low levels of fitness compared to controls matched for levels of activity and the poor aerobic fitness is associated with many of the cardiovascular risk factors.  Improvement in many of these risk factors has been linked to a decrease in plasma insulin levels and it is likely that many of the beneficial effects of exercise on cardiovascular risk are related to improvements in insulin sensitivity. (Zinman, B., Ruderman, P. etal; 1997)

Body Composition

Mr. Connor’s Body Mass Index is 40 and that puts him at the Extreme Obese Category.  http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html

Nutrition

            Nutrition is a critical component of Mr. Connor’s exercise program and ultimately must be adhered to for success in controlling and possibly reversing his diabetes.  Nutrition will consist of fresh fruits and vegetables that are on the low to moderate glycemic index, lean proteins, purified water, and fatty acids.  Diet will strictly minimize processed foods and foods and fruit drinks high in sugar.

Readiness for Change

            Mr. Connor’s level of exercise is Sedentary.  He has Type II Diabetes; he is obese, and he has not exercised in the past five years.  (Howley & Franks, pg. 284).   However, he scored well on the Readiness for Change form.  Mr. Connor understands his situation and is willing to begin an exercise program, a diet program and enter a  support program.

Motivational Strategies and Techniques

             Because Mr. Conner has a history of inactive lifestyle and poor eating habits and poor stress coping skills, it is recommended that we create a supportive environment to ensure his success in this program.  Information on the benefits of a lifetime commitment to exercise and lifestyle changes has been discussed and literature has been given to Mr. Conner, and he has been enrolled in a twice weekly support group to ensure adherence in the program. 

          Mr. Conner’s program will progress slowly.  The program is based on realistic goals and incorporates his needs and desires.  Behavioral change on Mr. Conner’s part includes compliance in all areas of the program in exercise, diet and stress coping skills.  Mr. Conner’s perception of his health status is keen.  He understands  that his health depends on his success in this program.  At this time his attitude is good and he seems self-motivated.

Motivational strategies include:

·         Positive behavioral feedback

·         Group participation and group support

·         Spousal support

·         Music therapy

·         Personal goal setting and charting

·         Recognition of accomplishments at meetings

·         The opportunity to go on a cruise when the weight goal has been reached

Recommendations

            Precautionary measures for Aerobic exercise involving Mr. Conner’s feet are essential.  The use of silica gel or air mid-soles as well as polyester or blend (cotton-polyester) socks to prevent blisters and keep the feet dry is important for minimizing trauma to the feet. Proper footwear is essential and must be emphasized due to possible peripheral neuropathy. Mr. Conner must be taught to monitor closely for blisters and other potential damage to their feet, both before and after exercise. A diabetes identification bracelet or shoe tag should be clearly visible when exercising. Proper hydration is also essential as dehydration can affect blood glucose levels and heart function adversely. Exercise in heat requires special attention to maintaining hydration. Adequate hydration prior to exercise is recommended (e.g. 17 ounces of fluid consumed two hours before exercise). During exercise fluid should be taken early and frequently in an amount sufficient to compensate for losses in sweat reflected in body weight loss, or the maximal amount of fluid tolerated. Precautions should be taken when exercising in extremely hot or cold environments. Moderate weight training programs that utilize light weights and high repetitions can be used for maintaining or enhancing upper body strength. (Zinman, B., Ruderman, P. etal; 1997).

          Mr. Connor’s estimated energy needs to sustain his metabolism is 155.02 calories per hour, or 3720.58 calories per day.  This is determined by:

Weight 265 lbs. divided by 2.2 = 120.45 grams

 x .9 = 108.41

108.41 X 24 = 2601.81 calories per day

Physical Activity Intensity Factor = 1.3 (Lab 7-2, Table 7.6 Thygerson Lab Manual, pg. 86)

2601.81 x 1.3 physical activity = 3382.35

3382.35 X .10 = 338.23 calories for TEF

3382.35 + 338.23 = 3720.58 calories per day

           Mr. Connor’s activity level factor is 1.3 very light.  (Thygerson & Larson 2006 pg. 86), and his thermogenic activity is 338.23 so he needs 3720.58 calories per day to sustain his weight, on days when he is sedentary.  (Thygerson & Larson 2006, pgs 85-86). In order to lose weight and increase carbohydrate metabolism and insulin sensitivity, he will need to raise his activity level factor to moderate by aerobic exercise 30-60 minutes per day 5-7 days per week and decrease his total caloric intake by 500 calories per day. 

References:

Marcus, B & Forsyth, L (2009).  Motivating People to be Physically Active, 2nd Edition. Human   Kinetics, Champaign, IL

Thygerson, Alton. &  Larson, K (2006).  Fit to be Well.  Sudbury, MA:  Jones and Bartlett Publishers

Thygerson, Alton. & Larson, K (2006).  Fit to be Well Lab Manual. Sudbury, MA: Jones and Bartlett Publishers

Zinman, B., Ruderman, P., Campaigne, B., Devlin, J., Schneider, S. (1997).

Diabetes Mellitus and Exercise, Medicine & Science in Sports & Exercise, December 1997, Vol 29, Issue 12, pp 1-6. Retrieved 4/17/10 from http://journals.lww.com/acsm-msse/Fulltext/1997/12000/Diabetes_Mellitus_and_Exercise.25.aspx#P45 at

http://www.acsm.org/ ACSM Position Stand on Exercise and Type 2 Diabetes

ADA/ACSM Diabetes Mellitus and Exercise Joint Position Paper

http://www.cdc.gov