The importance of physical exercise in all populations is very clear. Diabetes is a growing illness in most occidental or developed countries. Diabetics are a special population and personal trainers must know all specifications and steps to follow before starting a new training program with any T1DM patient.
In the other hand, physicians and physiotherapist should know and understand the importance of physical activity and physical exercise to improve health and quality of life in this population.
A transdisciplinary approach is needed to get results and minimize risk and negative interactions between treatments.
When we talk about diabetics, there are several factors to consider in order to find the perfect exercise program for each patient. Age, gender, fitness level, related or non-related health complications, time from diagnosis, etc. All these factors should be analyzed before starting a training program.
T1DM AND EXERCISE
DMT1 general concepts:
T1DM is associated with deficient insulin secretion due to the autoimmune destruction of pancreatic β cells and the need for exogenous insulin for survival.
Although several aspects of macronutrient metabolism are affected by T1DM, the alterations in carbohydrate metabolism (i.e., hyperglycemia) are the main characteristics of the disease. Indeed, chronic hyperglycemia is largely thought to be the mechanism by which vascular damage leading to diabetes-related complications, such as coronary artery disease (CAD), stroke, nephropathy, retinopathy, and neuropathy, occur over decades after disease onset (1).
Based on these data we can determine the importance of a deep health questionary or a complete report made by a health professional in which trainers can understand the patient´s health status attending to all possible factors, symptoms or illness related to T1DM.
Depending on specific needs, the exercise program should consider all these pathophysiological aspects to design a training program.
*If you need more information about physiopathology of T1DM, please check my biomedicine section.
Relationship patient-physical exercise:
There are no specific guidelines on the amount or intensity of physical activity needed to optimize health in persons with T1DM (1). That´s why trainers should be involved in a continuous learning process and consider each patient like a unique case.
The benefits of physical activity and physical exercise to prevent the development of the DMT1 or to treat its symptoms are very clear. These benefits can be summarized in:
- Improve insulin sensitivity (thereby reducing exogenous insulin requirement).
- Bodyweight control.
- Lipid profiles regulation.
- Boost self-confidence.
- Improvements in several psychological issues associated with the disease.
- Reduce systemic inflammation.
- Long- term protection against cardiovascular disease.
But trainers must empathize with the patient because for him some difficulties will appear when the start practising exercise like:
- Adjustment of insulin administration.
- Timing, type, and quantity of food ingestion before and after exercise.
- Unexpected hypo- and/or hyperglycemia during and after exercise.
- Non-accurate fatigue perception.
- Increased traumatism or bleeding (in advanced patients).
Part of our mission should be based on an educational program in which we can explain to them the reason for each one of these “problems” and help them to overcome them.
To increase weekly physical activity levels should be other of our educational aims during the first stages of the treatment.
Several studies have shown a poor correlation between physical activity and HbA1c levels.
But the scientific information is growing in this field and nowadays we know that patients who increase their weekly energy expenditure (more than 7000 calories a week) related to physical activity reduce dramatically their mortality risk and the risk of developing other health complications related to T1DM.
So for an inactive patient, we should consider help them to achieve this mínimum amount of physical activity in the short-mid term.
Before start talking about the specific steps all trainer should do before starting a program, I would like to summarize the American Diabetes Asociation recommendations related to exercise in T1DM patients (2) :
- Youth and adults with type 1 diabetes can benefit from being physically active, and activity should be recommended to all.
- Blood glucose responses to physical activity in all people with type 1 diabetes are highly variable based on activity type/timing and require different adjustments.
- Additional carbohydrate intake and/or insulin reductions are typically required to maintain glycemic balance during and after physical activity. Frequent blood glucose checks are required to implement carbohydrate intake and insulin dose adjustment strategies.
- Insulin users can exercise using either basal-bolus injection regimens or insulin pumps, but there are advantages and disadvantages to both insulin delivery methods.
- Continuous glucose monitoring during physical activity can be used to detect hypoglycemia when used as an adjunct rather than in place of capillary glucose tests.
Trainer´s considerations before the workout:
Clinical and physical activity history:
All people should do this process before starting an exercise program but, in diabetics patients, this process is very important and should include the proper questions and details.
Is well known that diabetes is linked to several illnesses like:
- Cardiovascular diseases.
- Neural diseases.
- Increased Oxidative stress
- Reproductive problems (men).
- Immune dysregulation and propensity to some infections.
How you can image, a lot of questions should be done related to these possible situations like medications, surgeries, related illness, sugar values, experience in sport and fitness fields, injuries….
I can´t create an official medical form for any type of patient, so I prefer to give you the links of several institutions to help you to find the perfect form for your business model and law regulation. Here you have several interesting links:
- Tallahassee Memorial Health Care Institution- form for diabetics
- Mckinley Health Center Illinois – Diabetes History Form
*You will find specific porpuses of forms and procedures in my courses and ebooks
Glucose control pre-workout
In the poorly controlled patient, specific structural changes may occur within the skeletal muscle fibre, which is considered by some to be a disease-specific myopathy. Further, even in well-controlled patients, several homeostatic mechanisms regulating carbohydrate metabolism often become impaired, causing hypo- or hyperglycemia during and/or after exercise (1).
That´s why professionals who work with these populations may have strict control of the patient and develop clear protocols to make correct decisions in all situations.
Each workout can be developed in different patient´s physiological status, so each day trainers must check the patient status and modifying their exercise plan if necessary.
The glycemic control is a procedure every trainer must develop before workouts with T1DM patients (and during and after it). Hyperglycemia can promote an excess of oxidative stress and inflammatory response after exercise. Hypoglycemia can result and an impaired glucose regulation during exercise (1).
Is important to analyze these values before the session and adjust the exercise factors and/or glucose levels (insulin administration) in order to warranty the safety and efficacy of our intervention.
We will explain this process in deep in the next post, considerations during a workout.
T1DM EXERCISE CONTRAINDICATIONS:
We have to do a detailed study, analyzing blood tests, signs and symptoms to be sure that there are no other health complications that we have to attend to, in addition to diabetes and insulin-glucose management.
Other diabetes-related complications including neuropathy, retinopathy, and nephropathy in persons with the long-standing disease are high and care should be taken to properly screen individuals before recommending a new exercise program (1).
Always try to do a stress/exercise test and medical check-up, before starting a training program of moderate or high intensities. During this test health professionals should measure glucose-insulin levels to create a first glucose-exercise intensity curve.
Trainers should take this data as a baseline and continuing doing measures along the exercise program to increase the accuracy of this curve and to adapt the exercise intensity/duration prescription to the patient’s progression.
Symptoms of chest pain or pressure are considered absolute contraindications to vigorous exercise (1). It doesn´t mean they can not do exercise but the intensity should be moderate-low and the patient should be controlled by a health specialist during the entire exercise program.
Following these simple rules, we will avoid the risk of a cardiovascular disease (CVD) event during a sesión.
- Galassetti P, Riddell MC. Exercise and type 1 diabetes (T1DM). Compr Physiol. 2013;3(3):1309–36.
- Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, et al. Physical activity/exercise and diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065–79.
- Tallhase Memorial Health Care Institution- form for diabetics– https://www.tmh.org/-/media/files/tmhpp/new-patient-history-form–diabetes-adult.pdf?la=en Consulted 01-29-2020
- Mckinley Health Center Illinois – Diabetes History Form – https://mckinley.illinois.edu/sites/default/files/docs/diabetes_history.pdf Consulted 01-29-2020