American Fitness Professionals & Associates

by Gary Scheiner, MS,

CDE Exercise helps pep up insulin’s action. Exercise can improve your health and your outlook on life. Because you have diabetes, however, it pays to be doubly careful not to injure yourself or upset your diabetes control. You should follow the basic guidelines that everyone who exercises needs to follow. And you’ll want to add some extra safety steps that take your diabetes into account. These 20 steps to safe exercise will help you deal with both of these needs.

Get a thorough medical exam before you start. Your doctor should check your blood pressure blood fat levels glycated hemoglobin levels health of heart and circulatory and nervous systems kidney function eyes and feet. Choose exercises that fit your health. Talk to your health care team about what types of exercise are best for you. Diabetes can cause health problems, such as eye or nerve disease, that make certain types of exercise poor choices. For example, if you have lost feeling in your feet, swimming may be better than walking.

If you have trouble seeing or have frequent low blood glucose reactions, you may need to exercise indoors or with a friend. Your health care team can help you choose fitness goals tailored to your health. Take it easy. Slow and steady wins the race. Trying to do too much too soon can leave you discouraged or even injured.

One way to pace yourself is to count your heart rate and make sure it stays below a certain level. Another is to rate how difficult exercise feels and avoid too much huffing and puffing. Your health care team can teach you how to avoid pushing yourself too hard. Step up your workout as you become more fit. Gradually increase how long and how hard you exercise. For instance, you may start out walking for just 5 or 10 minutes. Over many weeks, you may build up to 25 or 30 minutes. You and your health care team should adjust your plans for exercise, meals, and medications as you get in shape. Warm up and stretch when you start exercising. Warm up with a low-impact exercise like walking.

This gets your heart and muscles prepared to work. After you are warmed up, you may want to stretch gently. Stretching helps keep muscles and joints flexible. Tight muscles and joints are more prone to injury. End your workout with a cool-down. Slow down gradually, until your breathing becomes more normal. For example, if you’ve been jogging, walk for 5 minutes to cool down.

Some people prefer to stretch at the end of their workout, when muscles are warm and can stretch more easily.
When your breathing is back to normal, start your stretching routine. In addition to exercise that conditions your heart and lungs, try weight training. Almost everyone with diabetes can work out with light weights. You can enhance your upper body strength with an exercise program that features many repetitions with light, hand-held weights.

Drink plenty of fluids. Sweating means you’re losing fluid.
It’s important to drink to replace fluids lost in sweat. Water is usually the best choice. If you are exercising for a long time, you may want the extra calories in a drink that contains carbohydrate. Wear clothes that are right for the weather and your sport. It won’t help to wear heavy clothes in the warm weather. Sweating more won’t help you lose fat, just water weight. In fact, it’s unhealthy. You’ll just increase your risk of overheating. In the summer, wear lightweight, light-colored clothes. Be sure to use sunscreen and wear a hat.

In winter, dress in layers. Polypropylene, silk, or thin, fine wool make a good first layer. These materials help lift sweat from your body and prevent chafing. Your outer layer should be made of material that can “breathe” and let sweat escape. Be sure to protect your feet, hands, and head from the cold. Use the safety gear that goes with your sport.

If you’re cycling, wear a helmet. If you’re playing racquetball, wear eye protection. Avoid exercising when it’s too hot or too cold to be outside comfortably. It’s unhealthy to exercise outside when air quality is poor. Remember your feet.

Wear the right shoes for your sport. This means basketball shoes to play basketball, walking shoes for walking, aerobics shoes for aerobics, etc. Replace shoes when they begin to wear out. Always put on clean, smooth-fitting socks.

Check your feet after exercise. Look for blisters, warm areas, or redness. If you do see problems, call your doctor.
Watch for low blood sugar. If you take insulin or oral diabetes medicine, you may have low blood sugar levels during and after exercise. In fact, you may get low blood sugar 12 or more hours after a workout. People who have type 2 diabetes that is controlled by meal planning and exercise usually don’t have problems with low blood sugar. Glucose fuels your muscles during exercise.

At the same time, exercise helps pep up insulin’s action.
Both things lower your blood sugar level. Through careful planning, you and your doctor will learn to adjust your insulin treatment to avoid low blood sugar levels caused by exercise. Check your blood sugar before you exercise.

If you take insulin or diabetes pills, self-monitoring of blood glucose is the key to avoiding low blood sugar levels.
One good idea is to test your blood sugar twice before exercise. Monitor 30 minutes before and again just before you begin, so you’ll know whether your blood sugar level is stable or dropping. If it is dropping, you may need an extra snack. Be ready to check during exercise. This is especially important when you are trying a new activity or sport.

A check can help you predict how this sport will affect your blood sugar levels. You should also check if you will be exercising for more than 1 hour. Generally, you’ll want to test every 30 minutes. If your blood sugar starts to fall, stop and have a snack. Test again after exercise. Exercise-especially long, hard workouts-can lower your blood sugar for hours after you’ve stopped. This happens because workouts draw on your body’s supply of glucose, stored in your muscles and liver as glycogen. Later, your body rebuilds its stores of glycogen by taking glucose from the blood. For up to 24 hours, your body needs the glucose you get from meals to fill up your glycogen stores. Your health care team can suggest at what times you should do extra checks to avoid low blood sugar. Use your monitoring results to learn how exercise affects your body.

Exercise makes insulin work harder. Your blood sugar may drop more than usual when you take your normal insulin dose. Exercise can make insulin go to work faster, too.

On the other hand, if you have type 1 diabetes and have too little insulin available, hard exercise sessions can raise your blood sugar. Hard exercise can signal your liver to start breaking down glycogen into glucose. Hard exercise means whatever is difficult for you. Remember to test for ketones whenever your blood sugar levels are too high (see step 19). If you take insulin or diabetes pills to control your blood sugar levels, you need to plan your exercise and diabetes care to avoid levels that are too low or too high.

Time your exercise according to your meals and insulin. Generally, you want to exercise after you have eaten.
The food will help keep your blood sugar from becoming too low. It’s best to exercise 1-3 hours after a meal. You should also avoid exercising when your insulin is peaking (at its strongest). Avoiding your insulin’s peak times will help you avoid low blood sugar. Your doctor may suggest that you try decreasing the insulin dose that will be working while you exercise. Ask your health care team for tips about snacking and exercise. In general, exercise lowers blood sugar levels.

This can be good or bad, depending on your blood sugar level before you start to work out. If you have type 1 diabetes, and your preexercise sugar result is under 100 mg/dl, exercise could lower glucose too much. Have a carbohydrate-containing snack before beginning to work out.

Keep another snack handy to avoid low blood sugar levels during to exercise. On the other hand, people with type 2 diabetes should limit snacking to assist in weight loss. Snacking before exercise will undermine your efforts.

It will also work against the power of exercise to lower glucose levels. Be prepared to treat low blood sugar.
Always carry juice, regular (nondiet) soft drink, glucose gel, raisins, or another fast-acting source of sugar. If you feel a reaction coming on, stop, test, and treat it right away.
Know when not to exercise. If your fasting blood glucose is more than 300 mg/dl, no matter what type of diabetes you have, it is in poor control. Don’t exercise before you bring your glucose levels back down or before checking with your health care team. Know when to test for ketones. If you have type 1 diabetes and your blood glucose tests are 250 mg/dl before exercise, stop and test for ketones.

If you test positive for moderate or large amounts of ketones, do not exercise. Ketones are a sign that your insulin level is too low. Exercise could cause the body to make more ketones. Ketones add acid to the blood. When too many ketones are produced, they disrupt your body’s chemical balance. This can be dangerous. Wait until your tests show negative or trace ketone levels before beginning to exercise. Update your exercise plan regularly.

If you take insulin or diabetes pills, talk to your doctor about exercise and your blood sugar levels. Ask your doctor to tailor exercise guidelines to meet your individual needs.
Once you get going in a regular exercise program, you may find that you need less insulin or lower doses of diabetes pills. Your doctor may also be able to teach you how to change your own insulin dose on days when you plan a different exercise routine. Exercise with diabetes does demand a few extra safety steps. You’ll find that, once you’re into regular exercise, these will become a part of your routine. And the rewards of exercise are well worth a little extra effort.

Other related materials: For more information on how to exercise safely and successfully, click here to view The Fitness Book for People With Diabetes, by the American Diabetes Association or visit our Book Store. Tight Diabetes Control Tightly controlling your blood glucose levels gives you the power to prevent or slow some complications. Keeping your blood glucose levels as close to normal as possible can be a lifesaver.

Tight control can prevent or slow the progress of many complications of diabetes, giving you extra years of healthy, active life. But tight control is not for everyone-and it involves hard work. By The Numbers Tight control means getting as close to a normal (nondiabetic) blood glucose level as you safely can. Ideally, this means levels between 70 and 120 mg/dl before meals and less than 180 mg/dl after meals, with a glycated hemoglobin level less than 7 percent. (The target number for glycated hemoglobin will vary depending on the type of test your doctor’s laboratory uses.)

In real life, you should set your goals with your doctor. Keeping a normal level all the time is not practical. And it’s not needed to get results. Any reduction in blood glucose levels will help you prevent complications. What Tight Control Does No one knows exactly why high glucose levels cause complications in people with diabetes. But keeping glucose levels as low as possible prevents or slows some complications.

The Diabetes Control and Complications Trial (DCCT) proved it. Researchers followed 1,441 people with diabetes for several years. Half of the people continued standard diabetes treatment. The other half followed an intensive-control program. Those on intensive control kept their blood glucose levels lower than those on standard treatment although the average level was still above normal. The results?

Compared with the standard-treatment group, in the tight-control group: Diabetic eye disease started in only one-quarter as many people. Kidney disease started in only half as many people. Nerve disease started in only one-third as many people. Far fewer people who already had early forms of these three complications saw their conditions worsen.

Living With Tight Control To get tight control, you must pay more attention to your diet and exercise. You must measure your blood glucose levels more often. And, if you take insulin, you must change how much you use and when you use it. In intensive therapy, you provide yourself with a low level of insulin at all times and take extra insulin when you eat.

This pattern mimics the release of insulin from the normal pancreas. There are two ways to get more natural levels of insulin: multiple daily injection therapy and an insulin pump. Both are good methods. Your choice should depend on which fits into your life better. In multiple daily injection therapy, you take three or more insulin shots per day.

Usually, you take a shot of short-acting or Regular insulin before each meal and a shot of intermediate- or long-acting insulin at bedtime. With an insulin pump, you wear a tiny pump that releases insulin into your body through a plastic tube. Usually, it gives you a constant small dose of Regular insulin. You also have the pump release extra insulin when you need it, such as before a meal. With either method, you must test your blood glucose levels several times a day.

You need to test before each shot or extra dose of insulin to know how many units to take and how long before eating to take it. Also, you may want to test two or three hours after eating to make sure you took enough insulin. You must adjust your insulin dose for how much you plan to eat and how active you expect to be. You do not need to figure these things out on your own.

Whatever method you choose, your health care team (your doctor, dietitian, diabetes educator, and other health care professionals) should spend a lot of time teaching you about it. Your doctor may even put you in the hospital for a few days. Your team will help you make guidelines for how much insulin to take and when. You will also come up with guidelines for eating and exercising. All these guidelines will change several times as you test them out. You shouldn’t try tight control on your own.

A good health care team is a must. Choose a doctor who understands diabetes well or is willing to learn for your sake. Your doctor should have ties with other health professionals you need, such as a dietitian and a mental health worker. If you live in a small town, look at your options carefully.

You may be better off driving to a city to see a specialist. How To Keep Going And Going And Going Starting a program of tight control is exciting. But it can also be overwhelming. How do you keep from running out of energy? One way is to start slowly. For example, you might start by testing your blood glucose more often each day. Get used to that first.

Then start multiple daily injections. Once you’re used to those, then add on your new exercise program and make the changes in your diet. If you are newly diagnosed with diabetes, look honestly at yourself. Are you still angry and depressed that you have diabetes?

If so, you already have a big challenge facing you. You may want to wait to try tight control until after you’ve come to terms with the changes in your life. Keep your goals realistic. No matter how hard you try, your blood glucose readings will not be perfect every time. If they are often too high or too low, you should talk to your doctor about whether your plan needs to be adjusted. But if “wrong” levels happen only sometimes, that’s life. With practice, you will become more skilled at choosing the right insulin doses for various situations.

If you need to, take a breather from the new routine.
Having some time off may make it easier to stick to your plan when you start again. Pluses and Minuses One big reason to try tight control is to prevent complications later. But tight control has effects you can enjoy right now. You will probably feel better and have more energy. Also, because you adjust your insulin dose to your life, and not the other way around, you have more freedom.

You can vary your activities more. And you’re not locked into having meals at the same time each day. Tight control is especially good for pregnant women. It can reduce the risk of birth defects in the baby. But the DCCT found two major problems with tight control. First, people had three times as many low blood glucose reactions (hypoglycemia).

You will need to be alert to the symptoms of hypoglycemia so that you can treat yourself quickly. Also, you should always test your blood glucose levels before you drive. If you often have low blood glucose reactions when you try tight control, talk to your doctor. You may need to ease up on your goals or go back on standard therapy for a while.

Second, people on tight control gained more weight than people on standard insulin treatment. The average in the DCCT was 10 pounds. If you are concerned about putting on pounds, work with your dietitian and doctor to devise a meal and exercise plan to prevent it.

You should also consider the cost. You will need to see your health care team more often. Pumps cost about $4,500, and pump supplies run $60 to $80 a month. Multiple injection therapy is much cheaper. But you will still use more supplies, such as test strips and syringes, than before.

Tight Control And Type II Diabetes The DCCT studied only people with insulin-dependent (type I) diabetes. But doctors believe that tight control can also prevent complications in people with non-insulin-dependent (type II) diabetes. Most people with type II diabetes do not take insulin. You may be wondering how you can achieve tight control without it.

One way is to lose weight. Shedding excess pounds may bring your glucose levels down to normal. The key to losing weight and keeping it off is changing your behavior so that you eat less and exercise more. Your doctor should work with you to find an eating and exercise plan you can stick to.

Even if you don’t need to lose weight, exercise is helpful in controlling your blood glucose levels. It makes your cells take glucose out of the blood. You will need to test your blood glucose regularly. You should decide with your doctor how often. Once a day or even once a week may be enough for some people with type II diabetes.

If exercise and good eating habits are not enough to keep your glucose under control, your doctor may prescribe pills. And if these don’t work, you may need to take insulin.
People with type II diabetes should talk to their doctors before starting tight control.

Tight Control Is Not For Everyone Tight control is not safe for everyone with diabetes. Children should not be put on a program of tight control. Having enough glucose in the blood is vital to brain development. S

ome doctors say that tight control should wait until a child reaches 13; others say after the age of 7 is okay. Elderly people probably should not go on tight control.

Hypoglycemia can cause strokes and heart attacks in older people. Also, the major goal of tight control is to prevent complications many years later. Tight control is most worthwhile for healthy people who can expect to live at least 10 more years. Some people who already have complications should not be on tight control. For example, people with end-stage kidney disease or severe vision loss probably should not try it. Their complications are probably too far along to be helped. Some people who have coronary artery disease or vascular disease should not try tight control.

People who often have low blood glucose reactions probably should not go on tight control either. The Last Word on Childhood Diabetes If you have a child with diabetes, you have many concerns about his or her health. You also have moments when you simply want reassurance and the security of knowing that you are doing things right. Of course, your child’s doctor is your first resource for health matters.

But there will be situations in your child’s life when you’ll be called on to make judgments on your own. There will be times when you will have to reach into your own knowledge and understanding of insulin-dependent (type I) diabetes and take action. You’ll find such knowledge and understanding in a recent publication from the American Diabetes Association, Raising A Child With Diabetes. It is written by Linda Siminerio, RN, MS, CDE, and Jean Betschart, RN, MN, CDE, two professionals who are known and respected in the field.

The book covers many subjects including a basic explanation of what diabetes is; the role of health care providers; how to keep your child’s best interests at heart; different kinds of insulins and how to use them; site rotation; blood glucose testing; meal planning; games and sports; and special problems such as the dawn phenomenon, rebound, and infections. It even has tips for easier, less painful finger sticks.

Following is an excerpt from the book addressing the most serious problem your child may face: hypoglycemia. Hypoglycemia (Low Blood Glucose) Hypoglycemia is the most common problem in children with diabetes. Most of the time it is mild and can be easily treated by giving the child a sweet food. Food raises blood glucose levels and insulin and exercise lower them. Low blood glucose can occur when the balance of insulin, food, and exercise is upset.

The body can’t control insulin that’s given as an injection in the same way it controls insulin that the body makes itself. Once an injection is given, the insulin can’t be stopped or slowed down. So if too much insulin is available, blood glucose levels will drop too low.

People with diabetes have to control their own blood glucose levels because their bodies don’t do it for them. Eating meals and getting insulin injections at regular times and snacking before exercise help to prevent glucose levels from getting too low. Hypoglycemia needs to be treated promptly to prevent blood glucose levels from getting so low that the brain is deprived of glucose. Too little glucose in the brain can cause severe symptoms, such as: sleepiness and unresponsiveness, seizures, amd unconsciousness.

Alert Teacher A quick-witted teacher reported this experience with a usually pleasant and calm student: While waiting in the careteria line at lunch, the youngster became irritable and punched a classmate for no reason. The teacher guessed that the cause of the behavior might be low blood glucose and gave the student a glass of orange juice and some crachers. In about 15 minutes, after the juice and crackers began to raise her blood glucose level, the student became her usual pleasant self again.

How Can I Tell If My Child’s Blood Glucose Is Low?
The symptoms of low blood glucose may be different each time it happens. Sometimes your child may have no obvious symptoms. For these reasons, it is a good idea to teach a child with diabetes to tell you whenever he or she feels “strange” in any way. In children under 3, misbehavior or crankiness may be a sign that the child’s blood glucose is low. Very young children can’t tell you when they’re not feeling well. So you need to be on the lookout for warning signs. Frequent blood glucose tests can help to relieve parental anxiety. Most parents learn to recognize the symptoms of low blood glucose in their child.

It is a good idea to talk with your child’s teachers (and other adults whom your child has contact with) about the symptoms of low blood glucose. Scientists think that low blood glucose may continue to affect a child’s learning ability for a while (perhaps an hour or so) after it has been treated.

A period when your child’s glucose level is low may not be the best time for her or him to take an important exam or give a presentation. This is another reason why it’s a good idea to talk to your child’s teachers about low blood glucose.

The book also tells you what to do if your child has symptoms of low blood glucose, but the glucose levels are normal. Sometimes your child may feel nervous, anxious, or tired and think it’s because of low blood glucose.

She or he may have some of the symptoms of low blood glucose if the glucose level drops quickly from high to normal. The best thing to do if you or your child suspect that blood glucose is low is to do a blood test. If the child has symptoms of low blood glucose but the blood test shows the glucose isn’t low, she or he may be experiencing a fast drop in blood glucose levels without being in any danger of hypoglycemia. Giving the child a few crackers to eat will help the “low” feelings subside.

In a few minutes the child can return to normal activities.
If blood glucose levels are not low, eating a carbohydrate snack is not urgent. If in doubt, treat. If you think your child may have low blood glucose but you can’t do a blood test right away, give the child something sweet to eat. The treatment will not do any harm even if the child’s glucose level is not low.

Treating Low Blood Glucose Mild to moderate symptoms (child is alert and can swallow): Treat right away with a sweet food: 1/2 to 3/4 cup orange or apple juice 1 or 2 glucose tablets or doses of glucose gel 2 to 4 LifeSavers (or similar product) 1 or 2 Tbsp. honey Follow a few minutes later with: 2 to 4 soda crackers and 1 oz. of cheese OR 1 Tbsp. peanut butter (or other “complex” carbohydrate and protein)

Don’t Overeat: 1/2 cup (4 oz.) or orange juice or a glucose drink, followed by 4 crackers, should be enough to relieve syptoms. Remember that sugar takes time to be absosrbed. Give more sugar after about 15 minutes if the symptoms don’t go away. Severe symptoms (child is very sleepy, very shaky, unconscious, or unable to eat, drink, or swallow):

Treat immediately with an injection or glucagon. The standard does is 1 mg. However children up to age 6 usually only need 0.5 mg (half the standard dose). The injection should take effect in 15 to 20 minutes. If the child doesn’t respond, call your doctor or take the child to an emergency room.

Preventing Low Blood Glucose Low blood glucose can usually be prevented by: testing glucose levels regularly . following the recommended meal plan making sure the insulin dose is correct . eating extra snacks before exercise that is unplanned or more strenuous than usual. YOU MAY NEED TO REMIND your child that testing blood glucose helps to make sure that the insulin dose and meal plan are right.

If your child follows these guidelines and still has frequent episodes of low blood glucose, talk to your doctor or diabetes educator. Your child’s insulin dose or meal plan may need to be changed. If you and your child are trying to keep her or his glucose levels near normal, you can expect that she or he will have mild episodes of low blood glucose occasionally.

While not desirable, they are probably not dangerous and are easily treated. Treating Low Blood Glucose-Mild To Moderate Symptoms Low blood glucose needs to be treated quickly. The way to treat it is to give the child a sweet food like fruit juice, raisins, or glucose tablets, followed by four crackers.

If a candy bar is the only food available, it is an acceptable treatment for low blood glucose. Depending on how much food is already in the child’s stomach, it may take 10 to 20 minutes for the blood glucose level to rise. If your child isn’t feeling better in 20 minutes, check the blood glucose level again. If it’s still low, repeat the treatment.

A low blood glucose episode may occur just before a snack or a meal. If this happens, give the child something sweet and see that she or he eats the snack or meal as soon as possible. If a snack or meal isn’t coming soon, give the child a snack food containing complex carbohydrate and protein to follow the sweet food. Crackers with cheese or peanut but-ter, cereal and milk, or half a sandwich are good choices.

This food is eaten in addition to the day’s usual meals. Treating Low Blood Glucose-Severe Symptoms A child who is very drowsy, unconscious, or unable to eat, drink, or swallow may be experiencing severe low blood glucose.

Do not put anything in the child’s mouth if she or he is unconscious or likely to choke or clamp down on your fingers. If the child can’t or won’t swallow, you will need to give an injection of glucagon to raise blood glucose levels. (Glucagon is a hormone normally made by the pancreas.

Your doctor can give you a prescription for it.) The injection usually takes effect in 15 to 20 minutes. If the child does not respond within that time, contact your doctor or take the child to an emergency room right away.