| How to Begin Exercising
By Joel.B.Braunstein, MD. From Diabetes Forecast a publication
of the American Diabetes Association, August 2003, p.37-39.
SAFETY FIRST ! That should be the
mantra of anyone who wants to start an exercise program. Whether
its cardiovascular fitness youre after, or increased
muscle strength, or a combination of the two, your path to success
should begin with a health screening at your doctors office.
During your visit, your doctor will have you perform tests designed
to determine whether you body can handle the stress of exercise.
The idea is to take as much risk as possible out of exercise. He
or she will also help you establish health and fitness benchmarks,
so you can set goals and track improvements in your health over
time. Your doctors seal of approval will also help you build
the self-confidence and sense of security that youll need
as you begin a new exercise program. Youll also need to learn
about which activities you can safely perform, the types of footwear
and apparel you should wear, and the best approaches to preventing
blood sugar swings - both high and low - during and after exercise.
Understanding The Risks
As weve discussed in previous issues (for example, see Exercise
Paradox, April 2003, pages 36 - 39), there are several potentially
serious, often hidden, risks involved with exercise. Of these, a
sudden cardiac event like a heart attack or arrhythmia is the most
dangerous. Fortunately, these events occur only rarely and are largely
preventable with appropriate screening for risk factors and treatment.
Microvascular complications, like advanced retinopathy, also can
worsen during exercise.
Your doctor should assess your predisposition to these risks and
help you manage them appropriately. Under close medical supervision,
almost anyone can safely engage in some form of structured exercise.
Talk To Your Doctor
Your screening examination will generally begin with a dialog between
you and your doctor. This is your time to discuss any symptoms youve
recently experienced, as well as your past medical conditions.
Dont leave anything out. Even if your symptoms do not seem
to be related to your cardiovascular or diabetes health, bring them
up anyway. Thats because roughly 25 percent of those with
diabetes tend not to show the typical symptoms of heart disease,
which usually include chest pain and shortness of breath with exertion.
Neuropathy (nerve damage) can mask the way that an illness presents
itself. It may prevent you from feeling pain. Other indications
of nerve damage include heat and cold intolerance, erectile dysfunctions,
hypoglycemic unawareness (no awareness of low blood sugars), and
feelings of fullness upon eating even small meals, with frequent
bloating and nausea.
Nausea can also be a sign of heart and artery problems (also known
as cardiovascular disease or atherosclerosis) among people who have
diabetes and kidney disease, as can light-headedness and breaking
into clammy sweats. Hair loss on the lower legs, cold feet, and
muscle pain or cramps in the legs during exertion may signify peripheral
arterial disease (clogged arteries).
The Physical Examination
After reviewing your medical history, your doctor will examine
you. He or she will make sure your blood pressure is tightly controlled-otherwise,
some fitness activities could cause rapid, potentially dangerous
elevations in blood pressure.
A heart rate thats too fast when youre at rest could
be a sign of poor cardiovascular fitness overall or of autonomic
neuropathy (nerve damage to your organs), whereas diminished pulses
in your wrists and feet could indicate that the arteries that lead
to your hands and feet are narrowing because of atherosclerosis.
To screen for possible nerve damage to your feet, your doctor will
test your reflexes, your ability to sense vibrations and changes
in the positioning of your feet, and your ability to sense light
touch on the bottom of your feet through a monofilament test. To
screen for retinopathy and glaucoma, your primary doctor will probably
also want you to visit an ophthalmologist.
Your doctor may want to order appropriate tests or diagnostic studies,
depending upon the type of exercise that you intend to do (more
intense exercise require more careful screening) and your baseline
health. Simple blood and urine tests can determine your long-term
blood sugar control, cholesterol level, and kidney function. A treadmill
test, better known as a stress test, can detect if your blood flow
is limited, which would indicate the presence of coronary artery
disease. The results of this test will enable your doctor to gauge
whether your heart can handle the stress of regular physical activity.
Stress tests are especially useful for people with risk factors
that predispose them to cardiovascular disease.
The American Diabetes Association recommends a stress test for people
with diabetes who are embarking on a new exercise program and fall
into one of the following categories :
- Are over 25 years old AND have had type 2 diabetes for 10 years.
- Are over 25 years old AND have had type 1 diabetes for 15 years.
- Have additional cardiovascular risk factors beyond diabetes,
including high cholesterol, high blood pressure, or a family.
history of premature heart disease; smoking is also a risk factor.
- Have autonomic neuropathy.
- Have peripheral arterial disease.
Additional diagnostic studies to evaluate your heart health may
be warranted if you have an abnormal stress test, a prior history
of heart disease, or other test results (such as those from an electrocardiogram
or ECG) that preclude the use of a straightforward stress test.
Dont let all this scare you off. These tests are designed
to tease out problems that might not otherwise be obvious, but most
people do just fine on them. And even if problems are discovered,
you still have an advantage : You can deal with them at a much earlier
stage than otherwise would have been possible. If a problem does
exist, its most likely that you will be able to reduce your
risks and begin an exercise program anyway.
Together, you and your doctor should be able to design an individualized
exercise program that is tailored to your specific needs and interests
once the test results are in, whatever they are.
Endurance. Strength. Aerobic health. Weight
loss. These are just some of the many benefits you can reap
form exercise. But before you start, youll need a strong foundation
to build on. The cornerstone of that foundation is thorough, comprehensive
Joel B. Braunstein, MD, MBA, is an assistant professor and associate
director of the Clinical Trial Center, Division of Cardiology, at
Northwestern University Medical School, Chicago, Ill.
Before you start
ALTHOUGH most people with diabetes can exercise safely, exercise
involves some risks. To shift the benefit-to-risk ratio in your
favour, take these precautions :
- Have a medical exam before you begin your exercise program,
including an exercise test with EKG monitoring, especially if
you have cardiovascular disease, you are over 35, you have high
blood pressure or elevated cholesterol levels, you smoke, or you
have a family history of heart disease.
- Discuss with your doctor any unusual symptoms that you experience
during of after exercise.
- If you have diabetes-related complications, check with your
health care team about special precautions.
- Learn how to prevent and treat low blood sugar levels (hypoglycaemia).
If you take oral agents or insulin, monitor your blood sugar levels
before, during, and after exercise.
- If you have type 1 and your blood sugar is above 250 mg/dl,
check your urine for ketones. Dont exercise if ketones are
- Always warm up and cool down.
- Dont exercise outdoors when the weather is too hot and
humid or too cold.
- Pay special attention to proper footwear. Inspect your feet
daily and always after you exercise.
This column provides general guidelines and advice regarding exercise
and its role in the management of diabetes. This column is NOT intended
to offer individualized medical or exercise advice. The opinions
expressed in this column are the authors and do not necessarily
correspond to the views of the institutions he is associated with.