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How to Begin Exercising Safely

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 it’s cardiovascular fitness you’re after, or increased muscle strength, or a combination of the two, your path to success should begin with a health screening at your doctor’s 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 doctor’s seal of approval will also help you build the self-confidence and sense of security that you’ll need as you begin a new exercise program. You’ll 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 we’ve 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 you’ve recently experienced, as well as your past medical conditions.
Don’t leave anything out. Even if your symptoms do not seem to be related to your cardiovascular or diabetes health, bring them up anyway. That’s 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 that’s too fast when you’re 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.

The Tests

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.
Don’t 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, it’s 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, you’ll need a strong foundation to build on. The cornerstone of that foundation is thorough, comprehensive health screening.

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. Don’t exercise if ketones are present.
  • Always warm up and cool down.
  • Don’t 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 author’s and do not necessarily correspond to the views of the institutions he is associated with.