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Exercise for Diabetes by Selim
1. Exercise in DiabetesExercise in Diabetes
Exercise in
Diabetes Mellitus
Dr Shahjada SelimDr Shahjada Selim
Department of EndocrinologyDepartment of Endocrinology
Bangabandhu Sheikh Mujib Medical UniversityBangabandhu Sheikh Mujib Medical University
EmailEmail::selimshahjada@gmail.comselimshahjada@gmail.com
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2. DefinitionsDefinitions
Any bodily movement produced by the
skeletal muscles resulting in energy
expenditure above resting state.
Exercise in DiabetesExercise in Diabetes
Physical Activity
Caspersen, et al., Public health Rep,1985
11
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3. DefinitionsDefinitions
Exercise in DiabetesExercise in Diabetes
A set of attributes that people have or
achieve, which relates to the ability to
perform physical activity.
Caspersen, et al., Public health Rep,1985
11
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Physical Fitness
4. DefinitionsDefinitions
The amount of energy expended during
exercise relative to the energy expenditure
during rest.
Exercise in DiabetesExercise in Diabetes
Metabolic Equivalent (MET)
Energy expenditure during rest = 1 MET
= 3.5 ml of O2 / kg. min
= 1 kcal / kg. hr
22
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6. Classification of Exercise
Aerobic exercise:
Endurance type exercise, rhythmic,
sustained for sometimes.
Example:
Walking, jogging, running, cycling,
swimming, etc…
Exercise in DiabetesExercise in Diabetes
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66
7. Classification of ExerciseClassification of Exercise
Exercise in DiabetesExercise in Diabetes
Strength (Resistance) exercise:
Weight training with free weight,
machine, elastic rope, calisthenics, etc…
Flexibility exercise:
Stretching exercise.
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8. Physical Activity Intensity in MET
Light: Less than 3 MET
Exercise in DiabetesExercise in Diabetes
Moderate: 3 – 6 MET
Vigorous: Above 6 MET
CDC, 1996 January 1, 2016January 1, 2016
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10. Exercise in DiabetesExercise in Diabetes
What is the Amount of Physical ActivityWhat is the Amount of Physical Activity
that Promotes Health?that Promotes Health?
Moderate Intensity Physical Activity.
Energy Expenditure = 3 - 6 MET
That is: ≥ 30 min/day, ≥ 5 days/week.
150 min. per week.
ACSM, 2000; CDC, 1996
≥ 1000 k. calories/week.
Drygas, et al., 2000; Fletcher, et al., 1996; Lee, et al., 2000
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11. Exercise in DiabetesExercise in Diabetes
ExerciseExercise &&
DiabetesDiabetes
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12. Exercise in DiabetesExercise in Diabetes
Can Exercise PreventCan Exercise Prevent
oror Delay DiabetesDelay Diabetes ??
Evidences fromEvidences from
Randomized Clinical TrialsRandomized Clinical Trials
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13. Malmo
Study
Sweden 260males
(6 yrs)
Eriksson & Lindgarde,Eriksson & Lindgarde,
Diabetologia,Diabetologia, 1999119991
Da Qing, China China 577males &
Females (6 yrs)
Pan, et al,Pan, et al,
Diabetes Care,Diabetes Care, 19971997
The Nurse’s
Health Study
USA 70,000
Nurses (8 yrs)
Hu, et alHu, et al.,.,
JAMA,JAMA, 19991999
Finnish
Experimental
Study
Finland 523males&
Females (4 yrs)
Tuomilehto, et al.,Tuomilehto, et al., NN
Engl J Med,Engl J Med, 20012001
Diabetes
Prevention Study
USA 3234males &
Females (3 yrs)
Diabetes Prev. ProgramDiabetes Prev. Program
Research GroupResearch Group,,
N Engl J Med,N Engl J Med, 20022002
Exercise inExercise in
DiabetesDiabetes
Exercise in the Prevention of DiabetesExercise in the Prevention of Diabetes
Participants are either normal or haveParticipants are either normal or have ++ GTTGTT
15. Exercise in DiabetesExercise in Diabetes
Moderate Physical ActivityModerate Physical Activity
Performed Regularly for 120 – 200Performed Regularly for 120 – 200
min. per week reduces themin. per week reduces the
Incidence of diabetes in PeopleIncidence of diabetes in People
Predisposed to DiabetesPredisposed to Diabetes..
Exercise in the Prevention of diabetesExercise in the Prevention of diabetes
Summary of the ResultsSummary of the Results
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16. Exercise in DiabetesExercise in Diabetes
ExerciseExercise in thein the
Management ofManagement of
DiabetesDiabetes
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17. Exercise in DiabetesExercise in Diabetes
Exercise & Type 1 DiabetesExercise & Type 1 Diabetes
Improves physical fitness.Improves physical fitness.
Increases self confidence.Increases self confidence.
Improves CV function & CHD risk profile.Improves CV function & CHD risk profile.
It has no direct effect on glucose control.It has no direct effect on glucose control.
Proper timing of Exercise & Insulin.Proper timing of Exercise & Insulin.
Avoid strenuous exercise before bed time.Avoid strenuous exercise before bed time.
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19. 0
5
10
15
20
0 30 60 90 120 150 180
Before After
Exercise inExercise in
DiabetesDiabetes
Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 DiabeticsPlasmaGlucosePlasmaGlucose(mmol/l)(mmol/l)
TimeTime (min)(min)
12 months of Training12 months of Training
Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
20. 0
400
800
1200
1600
0 30 60 90 120 150 180
Before After
Exercise inExercise in
DiabetesDiabetes
Response toResponse to 100100 gg of glucose in mild Type 2 Diabeticsof glucose in mild Type 2 Diabetics
PlasmaInsulinPlasmaInsulin(pmol/l)(pmol/l)
TimeTime (min)(min)
12 months of Training12 months of Training
Holloszy, et al.Holloszy, et al. Acta Medica ScandActa Medica Scand 1986, 711: 55-651986, 711: 55-65
22. Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 1/41/4
Aerobic activity for 30Aerobic activity for 30 min.min. extendedextended (gradually)(gradually)
to 60to 60 min.min. every day or most days/week/ 150every day or most days/week/ 150
mins per wk.mins per wk.
HR during activity should be graduallyHR during activity should be gradually
increased to reach 60 – 70% of HR max.increased to reach 60 – 70% of HR max.
Exercise session should include 5-10 min. ofExercise session should include 5-10 min. of
warm-up and a 5 min of cool-down.warm-up and a 5 min of cool-down.
Exercise must involve most major muscles inExercise must involve most major muscles in
both lower and upper parts of the body.both lower and upper parts of the body.
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23. Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 2/42/4
Moderate intensity weight training programModerate intensity weight training program
is recommended to maintain muscle strengthis recommended to maintain muscle strength
( 8-12 repetitions 2 times /week).( 8-12 repetitions 2 times /week).
Exercise must be regular. Benefits areExercise must be regular. Benefits are
diminished after 1 -2 weeks of stopping .diminished after 1 -2 weeks of stopping .
For those with feet problems, avoid running.For those with feet problems, avoid running.
Alternate between walking, swimming, and cycling.Alternate between walking, swimming, and cycling.
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24. Exercise in DiabetesExercise in Diabetes
Exercise Prescription for DiabeticExercise Prescription for Diabetic 3/43/4
When using insulin, avoid exercise if glucoseWhen using insulin, avoid exercise if glucose
levels below 100 mg/dl or above 250 mg/dl.levels below 100 mg/dl or above 250 mg/dl.
Use proper shoes, with silica gel or air-filledUse proper shoes, with silica gel or air-filled
soles, and always keep feet dry.soles, and always keep feet dry.
Avoid dehydration by keeping your bodyAvoid dehydration by keeping your body
always hydratedalways hydrated..
Do not inject insulin into a body part that isDo not inject insulin into a body part that is
expected to be used during exercise.expected to be used during exercise.
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25. Exercise in DiabetesExercise in Diabetes
Graded Exercise Testing for DiabeticGraded Exercise Testing for Diabetic 4/44/4
It is recommended before any moderate toIt is recommended before any moderate to
high intensity exercise, especially if:high intensity exercise, especially if:
Age is > 35 yrs.Age is > 35 yrs.
Type 2 diabetes for > 10 yrs duration.Type 2 diabetes for > 10 yrs duration.
Type 1 diabetes for > 15 yrs duration.Type 1 diabetes for > 15 yrs duration.
Presence of any CHD risk factors.Presence of any CHD risk factors.
Presence of microvascular diseasePresence of microvascular disease
(retinopathy, nephropathy).(retinopathy, nephropathy).
Presence of peripheral vascular disease.Presence of peripheral vascular disease.
ADA Position Statement, Diabetes Care, 2002ADA Position Statement, Diabetes Care, 2002
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26. Exercise in DiabetesExercise in Diabetes
ExerciseExercise
Prescription forPrescription for
Special CasesSpecial Cases
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27. Exercise in DiabetesExercise in Diabetes
Diabetic withDiabetic with Peripheral NeuropathyPeripheral Neuropathy
Repetitive exercise on insensitive feet canRepetitive exercise on insensitive feet can
lead to ulceration & fractureslead to ulceration & fractures..
Peripheral neuropathy may results in lossPeripheral neuropathy may results in loss
of sensation in the feet.of sensation in the feet.
Limit weight-bearing exerciseLimit weight-bearing exercise (Treadmill,(Treadmill,
Prolonged walking, Jogging, Step exercise, etc..)Prolonged walking, Jogging, Step exercise, etc..)
Use proper shoes, and always monitor the feetUse proper shoes, and always monitor the feet..
Alternative exercises areAlternative exercises are: Swimming,: Swimming,
Bicycling, Arm exercise, Chair exercise, etc..Bicycling, Arm exercise, Chair exercise, etc..
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28. Exercise in DiabetesExercise in Diabetes
Diabetic withDiabetic with Autonomic NeuropathyAutonomic Neuropathy
Hypotension and hypertension are moreHypotension and hypertension are more
likely to develop after vigorous exercise.likely to develop after vigorous exercise.
This condition may limit exercise capacity &This condition may limit exercise capacity &
increase the risk of CV event during exercise.increase the risk of CV event during exercise.
Those patients may have difficulty withThose patients may have difficulty with
thermoregulation:thermoregulation:
Avoid exercise in hot or cold environments.Avoid exercise in hot or cold environments.
encourage adequate hydration.encourage adequate hydration.
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29. Hypoglycemia during or after ExerciseHypoglycemia during or after Exercise
It will most likely occur if the patient:
Takes insulin or diabetes pill.
Skips a meal.
Exercises for a long time.
Exercises strenuously.
Exercise in DiabetesExercise in Diabetes
If it occurs, what can be done?
Patient must eat a snack before exercise, or.
Adjusts the medication dose.
Remember: Patient should always carry a source
of CHO with him ( An apple or orange juice, or a piece of
fruit).
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30. Exercise in DiabetesExercise in Diabetes
Energy ExpenditureEnergy Expenditure
duringduring
Physical Activity!Physical Activity!
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31. ActivityActivity CaloreiCalorei
Brisk walkingBrisk walking 0.070.07
RunningRunning (7.5 min per km)(7.5 min per km) 0.130.13
RunningRunning (5 min per km)(5 min per km) 0.2080.208
SwimmingSwimming 0.1620.162
Rope skippingRope skipping (70/min)(70/min) 0.1620.162
Rope skippingRope skipping (80/min)(80/min) 0.1650.165
BadmintonBadminton 0.0970.097
TennisTennis 0.1090.109
SquashSquash 0.2120.212
BasketballBasketball 0.1380.138
Energy Cost of Physical ActivityEnergy Cost of Physical Activity
((kilocalorie/kg. minkilocalorie/kg. min))
McArdle, et., 1991
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32. ActivityActivity METMET
WalkingWalking (slow)(slow) 2.52.5
Walking (Walking (Brisk)Brisk) 44
RunningRunning (7.5 min per km)(7.5 min per km) 88
SwimmingSwimming 66
Rope skippingRope skipping (slow)(slow) 88
Weight trainingWeight training 66
BadmintonBadminton 4.54.5
TennisTennis (single)(single) 88
SquashSquash 1212
BasketballBasketball 88
Energy Cost of Physical ActivityEnergy Cost of Physical Activity
((METMET))
Ainsworth, et., 2000
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33. Exercise in DiabetesExercise in Diabetes
How to CalculateHow to Calculate
Energy ExpenditureEnergy Expenditure
during Brisk Walkingduring Brisk Walking!!
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34. Exercise in DiabetesExercise in Diabetes
== 0.070.07 k.k. caloriecalorie per kg of body weightper kg of body weight //
min.min.
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
An Example:An Example:
aa person weighing 76 kg would expend:person weighing 76 kg would expend:
0.070.07 X 76 =X 76 = 5.35.3 k.k. calorie per min.calorie per min.
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35. Exercise in DiabetesExercise in Diabetes
Energy Expenditure during Brisk WalkingEnergy Expenditure during Brisk Walking
If he has to expend 1200 k.If he has to expend 1200 k. calories per week.calories per week.
How much time he should walk per week?How much time he should walk per week?
1200 / 5.3 = 226.4 min.1200 / 5.3 = 226.4 min.
= 45 min / 5 days per week, or= 45 min / 5 days per week, or
= 57 min / 4 days per week.= 57 min / 4 days per week.
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36. Preparing For Exercise
Proper warm-up
consisting of 5–10 min of
aerobic activity
Activity session 15- 30
mins
cool-down should be
structured similarly to
the warm-up and
should last about 5–10
min
37. Types of Physical Activity
The Mnemonic: “SAFE” exercises are
recommended:
Strengthening exercises
Aerobic exercises
Flexibility exercises
Endurance exercises
38. Aerobic exercise
With Oxygen
Aerobic exercise is the type
that moves large muscle
groups and causes you to
breathe more deeply and
your heart to work harder to
pump blood. It's also called
cardiovascular exercise. It
improves the health of your
heart and lungs.
39. Anaerobic (Resistance) Exercise
Anaerobic exercise
uses large muscles
that do not require
oxygen for short
periods of exercise. It
helps build strong
muscles; lowers blood
glucose makes the
action of insulin more
effective.
40. Flexibility (Stretching) Exercise
Flexibility exercises are
aimed at increasing or
maintaining range of
motion at joints, also
improve tone in muscles
and keep it supple.
They develop better
muscular and body
control.
41. Endurance Exercises
Low Resistance, High
Repetition Exercises
Examples:
Walking, cycling,
swimming, or upper
extremity ergometry
that involve the use of
the large muscle of the
body.
42. How much exercise?
Exercises should be done according to FITT principle.
FREQUENCY: Exercising 4 to 6 times a week.
INTENSITY: 30-40 min of exercise at 50- 60 % of target
heart rate.
TYPE: SAFE exercises are recommended.
TIME: Morning is ideal
43. A SAMPLE WALKING PROGRAM
Warm Up Target Zone Exercising Cool Down Time Total
Week 1
Session A Walk normally 5 min. Then walk briskly 5 min. Then walk normally 5 min. 15 min.
Session B --Repeat above pattern--
Session C --Repeat above pattern--
Continue with at least three exercise sessions during each week of the program. If you find a particular week's pattern tiring, repeat it before going on to the next pattern. You
do not have to complete the walking program in 12 weeks.
Week 2 Walk 5 min. Walk briskly 7 min. Walk 5 min. 17 min.
Week 3 Walk 5 min. Walk briskly 9 min. Walk 5 min. 19 min.
Week 4 Walk 5 min. Walk briskly 11 min. Walk 5 min. 21 min.
Week 5 Walk 5 min. Walk briskly 13 min. Walk 5 min. 23 min.
Week 6 Walk 5 min. Walk briskly 15 min. Walk 5 min. 25 min.
Week 7 Walk 5 min. Walk briskly 18 min. Walk 5 min. 28 min.
Week 8 Walk 5 min. Walk briskly 20 min. Walk 5 min. 30 min.
Week 9 Walk 5 min. Walk briskly 23 min. Walk 5 min. 33 min.
Week 10 Walk 5 min. Walk briskly 26 min. Walk 5 min. 36 min.
Week 11 Walk 5 min. Walk briskly 28 min. Walk 5 min. 38 min.
Week 12 Walk 5 min. Walk briskly 30 min. Walk 5 min. 40 min.
Week 13 and thereafter:
Check your pulse periodically to see if you are exercising within your target zone. As you get more in
shape, try exercising within the upper range of your target zone. Gradually increase your brisk
walking time to 30 to 60 minutes, three or four times a week.
53. Hypoglycemia Management
The person should be instructed to stop
exercising. People at risk for hypoglycemia
should always carry a source of glucose with
them such as glucose tablets, candy or juice in
order to treat hypoglycemia.
Remember- it is a medical emergency
54. Snacking to prevent hypoglycemia
Basic Rules:
Snack prior to activity to prevent hypoglycemia
Adjust quantity based on pre-activity BG or direction of BG
BG low or dropping: usual carbs
BG OK or stable: usual carbs
BG High or rising: usual carbs
Snack at least once per hour during prolonged activity
Choose high-glycemic forms of carbohydrate
Source: Scheiner, Gary: Think Like A Pancreas, Marlowe Publishing, NY, 2005
55. Useful Tips For Exercise
Always carry an
identification card with you
Check your feet before you
walk
Choose good footwear,
light clothing
Drink lots of water
Don’t exercise during hot
seasons, and when not
feeling well
63. What Can Physical Activity Do
For You?
Improve
blood
glucose
control
(lowers A1C)
64. Physical activity lowers blood
glucose in type 2 diabetes by
helping:
muscle cells become more sensitive to insulin
keep the liver from producing too much glucose
build more muscle
you lose weight and keep it off
67. “Sitting” through life increases
your risk of:
heart disease
high blood pressure
high cholesterol
overweight
type 2 diabetes
68. We now must plan physical
activity into our schedule
69. Getting Started
Check with your doctor if you:
Are over age 35
Have had diabetes more than 10
years
Have high blood pressure, heart
disease, poor circulation, or other
diabetes complications
72. Stretching
Improves your balance and
coordination
Makes you more flexible
Reduces stiffness
Reduces your risk of injury
73. How Can You Begin?
Choose activity (example: brisk walking)
Set a long-term goal - at least 30
minutes a day, 3-5 days a week
Buy comfortable walking shoes
Get a partner
Point to discuss:
Exercise is ONE of the ingredients that contributes to diabetes management
People with peripheral neuropathy should not undertake weight-bearing exercise. They should be advised to undertake non-weight-bearing exercise such as exercise bike, swimming etc.
Exercise that increases blood pressure, and therefore renal perfusion, is contraindicated in people with nephropathy.
Caution needs to be taken to avoid a bleed in people with significant diabetic retinopathy.
Some people feel like they don’t have enough energy to exercise. But, if you give it a chance, you’ll find that physical activity gives you more energy than you’ve ever had – allowing you to do the things you previously felt you didn’t have enough energy to do.
Exercise boosts your metabolism and helps you burn extra calories, even after you’re done exercising.
Exercise combined with eating less can help you lose weight and keep if off. The pounds come off faster and stay off if you add exercise.
Even a small amount of weight loss (10-20 lbs) can improve your blood glucose levels if you’re overweight.
Exercise can help you stay independent as you get older. It decreases the risk of muscle and joint injury, aches and pains. It slows bone loss as you age.
We naturally lose muscle as we age. Physical activity helps not only prevent muscle loss, but also build muscle and lose fat.
Studies show that regular physical activity can help prevent some of the sexual problems that can be caused by aging, lack of physical activity, and high blood glucose levels.
Regular physical activity can improve your self-image, make you feel better about yourself, and lift your mood. You can not only make yourself happier, but also those around you. In fact, exercise training has been shown to be comparable to seeing a therapist or taking medication for depression.
Stress and anxiety can lead to overeating. If you overeat as a way to cope with stress, you’ll find that exercise is a better coping mechanism.
If you have type 2 diabetes, exercise can improve your blood glucose control.
Let’s look at how it does that.
Physical activity helps your muscles use insulin more efficiently, so you need less insulin. This blood-glucose lowering effect only lasts a few days after exercise, so to get the most out of your exercise, try to do some physical activity every day (or at least 3-5 days a week).
Your liver begins making less glucose as it becomes more sensitive to insulin.
More muscle means lower glucose. Muscle uses more glucose, even at rest.
Exercise helps you lose weight and keep it off. A loss of even 10-20 lbs can really improve your blood glucose.
Exercise is also beneficial for type 1 diabetes, but usually does not improve blood glucose control unless insulin and food intake are well balanced with physical activity.
When you have diabetes, you have a much higher risk of heart disease, so exercise is especially beneficial to your heart.
1. A strong heart does a better job of pumping blood throughout the body.
2. Reducing the resting heart rate and blood pressure put less work on the heart.
3. Exercise lowers total cholesterol, raises HDL (good) cholesterol, and lowers triglycerides
4. All of these help reduce your risk of heart attack and stroke.
Modern technology like elevators, dishwashers, washing machines, remote controls, and computers has eliminated the daily chores and activities of your grandparents era.
Inactivity has made us sitting ducks for diseases like heart disease, high blood pressure, high cholesterol and other blood fats, obesity and overweight, and type 2 diabetes.
(Ask audience to stop and figure how much time each day is spent sitting and being inactive.)
It’s not a leisure activity that you do only if you have time. It’s necessary if you want to stay healthy.
It’s been said that instead of checking with your doctor to see if you can exercise, people with diabetes should check with their doctor if they are thinking of NOT exercising.
It is recommended to find out if you have any limitations (we don’t mean excuses!) and if you should emphasize certain types of activities over others if you are over 35 years old, have had diabetes for more than 10 years, or have certain medical conditions. This does NOT mean you shouldn’t exercise! It simply means talk to your doctor so they can support you in your effort and help you come up with safe and enjoyable ways of increasing your activity level.
When you do activities like walking, mowing the lawn, dancing, swimming, biking, or vacuuming, you use the large muscles in your body in a continuous, repetitive way. These types of activities can improve your health by strengthening your muscles (including your heart), promoting weight loss, reducing blood glucose, and improving your stamina and energy level.
Activities that require pushing, pulling, and lifting – or resistance activities – can help strengthen specific muscles or groups of muscles. They also improve balance and reduce risk of falls, reduce your risk of osteoporosis and bone fracture, increase your energy level and increase your body’s sensitivity to insulin.
You can do stretching anytime, anywhere. Stretching improves your balance and coordination. Stretch during breaks throughout the day and after you complete your exercise during the cool-down to increase flexibility and prevent soreness and injury.
First choose a type of activity that you will enjoy and that’s convenient for you. Walking is the most popular type of exercise and it’s safe for most people to do. If you are unable to walk, you might choose swimming, chair exercises, or water exercises.
Set your long-term goal – to get the most benefit from physical activity, it’s recommended to be moderately active at least 30 minutes, 3-5 days a week.
Be sure to wear appropriate clothing and shoes for the activity you select.
Walking with a partner can help keep you motivated and provide some support. But, don’t rely on a partner who is not totally committed – that can actually be detrimental to your success.
Regular physical activity can do more for type 2 diabetes than any pill could ever do. Like a magic wand, exercise can transform your body, your health and you.