2008 Clinical Practice Guidelines - Canadian Diabetes Association

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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.
4. Laaksonen DE,Atalay M, Niskanen LK, et al.Aerobic exercise and the lipid profile in type 1 diabetic men: a randomized controlled trial. Med Sci Sports Exerc. 2000;32:1541-1548. 5. Hu G, Jousilahti P, Barengo NC, et al. Physical activity, cardiovascular risk factors, and mortality among Finnish adults with diabetes. Diabetes Care. 2005;28:799-805. 6. Hu FB, Stampfer MJ, Solomon C, et al. Physical activity and risk for cardiovascular events in diabetic women. Ann Intern Med. 2001;134:96-105. 7. Gregg EW, Gerzoff RB, Caspersen CJ, et al. Relationship of walking to mortality among US adults with diabetes. Arch Intern Med. 2003;163:1440-1447. 8. Church TS, LaMonte MJ, Barlow CE, et al. Cardiorespiratory fitness and body mass index as predictors of cardiovascular disease mortality among men with diabetes. Arch Intern Med. 2005;165:2114-2120. 9. Moy CS, Songer TJ, LaPorte RE, et al. Insulin-dependent diabetes mellitus, physical activity, and death. Am J Epidemiol.1993; 137:74-81. 10. Nielsen PJ, Hafdahl AR, Conn VS, et al. Meta-analysis of the effect of exercise interventions on fitness outcomes among adults with type 1 and type 2 diabetes. Diabetes Res Clin Pract. 2006;74:111-120. 11. Balducci S, Iacobellis G, Parisi L, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications. 2006;20:216-223. 12. Jakicic JM, Winters C, Lang W, et al. Effects of intermittent exercise and use of home exercise equipment on adherence, weight loss, and fitness in overweight women: a randomized trial. JAMA. 1999;282:1554-1560. 13. Murphy MH, Hardman AE. Training effects of short and long bouts of brisk walking in sedentary women. Med Sci Sports Exerc. 1998;30:152-157. 14. Eves ND, Plotnikoff RC. Resistance training and type 2 diabetes: considerations for implementation at the population level. Diabetes Care. 2006;29:1933-1941. 15. Castaneda C, Layne JE, Munoz-Orians L, et al. A randomized controlled trial of resistance exercise training to improve glycemic control in older adults with type 2 diabetes. Diabetes Care. 2002;25:2335-2341. 16. Dunstan DW, Daly RM, Owen N, et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care. 2002;25:1729-1736. 17. Durak EP, Jovanovic-Peterson L, Peterson CM. Randomized crossover study of effect of resistance training on glycemic control, muscular strength, and cholesterol in type 1 diabetic men. Diabetes Care. 1990;13:1039-1043. 18. Sigal RJ, Kenny GP, Boulé NG, et al. Effects of aerobic exercise training, resistance exercise, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med. 2007; 147:357-369. 19. Riddell MC, Perkins BA. Type 1 diabetes and vigorous exercise: applications of exercise physiology to patient management. Can J Diabetes. 2006;30:63-71. 20. Sigal RJ, Purdon C, Fisher SJ, et al. Hyperinsulinemia prevents prolonged hyperglycemia after intense exercise in insulindependent diabetic subjects. J Clin Endocrinol Metab. 1994;79: 1049-1057. 21. Tsalikian E, Mauras N, Beck RW, et al. Impact of exercise on overnight glycemic control in children with type 1 diabetes mellitus. J Pediatr. 2005;147:528-534. 22. Dubé MC, Weisnagel SJ, Prud’homme D, et al. Exercise and newer insulins: how much glucose supplement to avoid hypoglycemia? Med Sci Sports Exerc. 2005;37:1276-1282. 23. Rabasa-Lhoret R, Bourque J, Ducros F, et al. Guidelines for premeal insulin dose reduction for postprandial exercise of different intensities and durations in type 1 diabetic subjects treated intensively with a basal-bolus insulin regimen (ultralente-lispro). Diabetes Care. 2001;24:625-630. 24. Sonnenberg GE, Kemmer FW, Berger. M. Exercise in type 1 (insulin-dependent) diabetic patients treated with continuous subcutaneous insulin infusion: prevention of exercise-induced hypoglycaemia. Diabetologia. 1990;33:696-703. 25. Perkins BA, Riddell MC. Type 1 diabetes and exercise: using the insulin pump to maximum advantage. Can J Diabetes. 2006; 30:72-79. 26. Harris SB, Petrella RJ, Leadbetter W. Lifestyle interventions for type 2 diabetes. Relevance for clinical practice. Can Fam Physician. 2003;49:1618-1625. 27. Eden KB, Orleans CT, Mulrow CD, et al. Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:208-215. 28. Petrella RJ, Koval JJ, Cunningham DA, et al. Can primary care doctors prescribe exercise to improve fitness? The Step Test Exercise Prescription (STEP) project. Am J Prev Med. 2003; 24:316-322. 29. Kirk A, Mutrie N, MacIntyre P, et al. Effects of a 12-month physical activity counselling intervention on glycaemic control and on the status of cardiovascular risk factors in people with Type 2 diabetes. Diabetologia. 2004;47:821-832. 30. Wolf AM, Conaway MR, Crowther JQ, et al.Translating lifestyle intervention to practice in obese patients with type 2 diabetes: Improving Control with Activity and Nutrition (ICAN) study. Diabetes Care. 2004;27:1570-1576. 31. Norris SL, Zhang X, Avenell A, et al. Long-term non-pharmacologic weight loss interventions for adults with type 2 diabetes. Cochrane Database Syst Rev. 2005(2):CD004095. S39 MANAGEMENT
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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