2008 Clinical Practice Guidelines - Canadian Diabetes Association

2008 CLINICAL PRACTICE GUIDELINES
S38
Table 1. Aerobic exercise
Definition and
recommended
frequency
Rhythmic, repeated
and continuous
movements of the
same large muscle
groups for at least
10 minutes at a time
Recommended for
a minimum of 150
minutes per week
(moderate intensity)
Table 2. Resistance exercise
Definition Recommended
frequency
Activities that
use muscular
strength to
move a weight
or work against
a resistant load*
Intensity Examples
Moderate:
50–70%
of person’s
maximum
heart rate
Vigorous:
>70% of
person’s
maximum
heart rate
3 times per week
• Start with 1 set of
10–15 repetitions
at moderate weight
• Progress to 2 sets
of 10–15 repetitions
• Progress to 3 sets
of 8 repetitions at
heavier weight
• Biking
• Brisk walking
• Continuous swimming
• Dancing
• Raking leaves
• Water aerobics
• Brisk walking up
an incline
• Jogging
• Aerobics
• Hockey
• Basketball
• Fast swimming
• Fast dancing
Examples
• Exercise with
weight machines
• Weight lifting
*Initial instruction and periodic supervision are recommended
can be lifted 8 times), 3 times per week (15,16) or more (17).
The effects of resistance exercise and aerobic exercise are
additive (18). Individuals who wish to begin resistance exercise
should receive initial instruction and periodic supervision
by a qualified exercise specialist.
During and after all but the most intense exercise, blood
glucose tends to decline due to increased glucose disposal
and insulin sensitivity (19). However, during and especially
after brief, very intense exercise (e.g. competitive track and
field, hockey, basketball, intense resistance training), blood
glucose will rise as a result of increases in glucose production
that exceed increases in glucose disposal (20). Exercise late
in the day can be associated with increased risk of overnight
hypoglycemia in people with type 1 diabetes (21). In type 1
diabetes, small studies have explored 3 types of strategies for
the prevention of hypoglycemia using protocols that generally
involve postprandial exercise.These strategies include the
consumption of extra carbohydrates for exercise (22), limiting
preprandial bolus insulin doses (23) or altering basal
insulin for insulin pump users (24). These strategies can be
used alone or in combination (25).
Despite a strong body of evidence supporting the health
benefits of lifestyle modification in people with type 2 diabetes,
application in medical care settings remains a challenge
(26). Healthcare professionals can heighten awareness of the
importance of physical activity by promoting regular exercise
as a key component of therapy and identifying resources in
the community (27). Structured physical activity counselling
by a physician (28) or skilled healthcare personnel or case
managers (29,30) has been very effective in increasing physical
activity, improving glycemic control (29), reducing the
need for oral antihyperglycemic agents and insulin (30), and
producing modest but sustained weight loss (31).
RECOMMENDATIONS
1. People with diabetes should accumulate a minimum of
150 minutes of moderate- to vigorous-intensity aerobic
exercise each week, spread over at least 3 days of the
week, with no more than 2 consecutive days without
exercise [Grade B, Level 2, for type 2 diabetes (3); Grade C,
Level 3, for type 1 diabetes (9)].
2. People with diabetes (including elderly people) should
also be encouraged to perform resistance exercise 3
times per week [Grade B, Level 2 (15,16)] in addition to
aerobic exercise [Grade B, Level 2 (18)]. Initial instruction
and periodic supervision by an exercise specialist are
recommended [Grade D, Consensus].
3.An exercise ECG stress test should be considered for
previously sedentary individuals with diabetes at high
risk for CVD who wish to undertake exercise more
vigorous than brisk walking [Grade D, Consensus].
OTHER RELEVANT GUIDELINES
Monitoring Glycemic Control, p. S32
Insulin Therapy in Type 1 Diabetes, p. S46
Hypoglycemia, p. S62
Identification of Individuals at High Risk of Coronary Events,
p. S95
Screening for the Presence of Coronary Artery Disease,
p. S99
Vascular Protection in People With Diabetes, p. S102
REFERENCES
1. Sigal RJ, Kenny GP, Wasserman DH, et al. Physical activity/
exercise and type 2 diabetes: a consensus statement from the
American Diabetes Association. Diabetes Care. 2006;29:1433-
1438.
2. Wing RR, Goldstein MG, Acton KJ, et al. Behavioral science
research in diabetes: lifestyle changes related to obesity, eating
behavior, and physical activity. Diabetes Care. 2001;24:117-123.
3. Snowling NJ, Hopkins WG. Effects of different modes of exercise
training on glucose control and risk factors for complications
in type 2 diabetic patients: a meta-analysis. Diabetes Care.
2006;29:2518-2527.