Solve Your Exercise Dilemmas-Three Case Studies

A study published in the December 1998 issue of the Canadian Journal of Diabetes Care says that regular exercise is an important component of the treatment regimen for all people with diabetes. Gayle Lorenzi, RN, CDE, who conducted the study at the University of California, San Diego, says that exercise, when combined with dietary management and drug therapy, generally contributes to improved blood glucose control, as well as decreased cardiac risk, blood pressure control, lipid profiles and psychological well-being. Oftentimes, however, initiating an exercise program is a tough sell for most diabetes physicians and educators. The decision to start an exercise program requires motivation to get started, and then a commitment to maintaining the program.

Lorenzi mentions three case profiles that illustrate intervention strategies used to incorporate physical activity into patients’ daily routines.

A Sedentary Life

The first is a 60-year-old female who had been diagnosed with type 2 diabetes six years prior to the study. The woman weighed 276 pounds, and was taking metformin to improve her blood glucose levels. The woman had not exercised in recent memory, and her understanding of the benefits of exercise was limited.

Her negotiated exercise plan was to start walking three to five minutes per day, and to increase the number of minutes per day in one- to two-minute increments. She was originally evaluated every two to three weeks, and then every six to eight weeks with continued emphasis on increased exercise duration. Nine months after her initial evaluation, the woman had lost 33 pounds, and her HbA1c value had fallen to 6.5%.

Triathlete

The second profile involves a 32-year-old male with type 1 diabetes who was a triathlete. At least three times a week he spent an average of 3 hours and 45 minutes a day lifting free weights, running, cycling and swimming. His daily insulin regimen was 45 units of NPH each morning, with supplemental doses of Regular before dinner. He said that he experienced mild hypoglycemia approximately four times per week, and instances of mild hypoglycemia increased in frequency and severity as he trained more intensely. He tried stopping insulin on competition days, but that resulted in decreased stamina and marked high blood sugar.

His negotiated exercise plan was to monitor his blood glucose more frequently when exercising. If he was exercising for less than 30 minutes, he should add a snack and/or make an insulin adjustment. If he was exercising for more than 30 minutes, he should reduce insulin 10 to 20 percent and consume 10 to 30 grams of carbohydrate every 30 to 60 minutes. And if he was engaging in prolonged and vigorous exercise, he should reduce insulin 30 to 50 percent (prior to and up to 12 to 24 hours after vigorous exercise) and consume 10 to 30 grams of carbohydrates every 30 to 60 minutes.

As a result of this program, the athlete demonstrated better blood glucose control, and his HbA1cs dropped to 6.9% without further episodes of hypoglycemia.

Workaholic

The third profile is of a 44-year-old male with an 18-year history of type 1 diabetes. HbA1c values were 8 to 8.4%, and his exercise was limited to working on his motorcycle on the weekends. He also smoked approximately 40 cigarettes per day, and experienced shortness of breath with minimal exertion. The man wanted to lose weight and exercise more, but was uncertain how he could implement a regimen in the midst of his fast-paced life. He identified walking as an exercise he could do while “on the road.”

The negotiated exercise plan was to walk each evening for five to 10 minutes, gradually increasing the duration over time. After one year, he was still living a fast-paced lifestyle and smoking 30 to 40 cigarettes per day, but HbA1c levels had dropped to 7.3%, and he had lost 12 pounds.

Lorenzi concluded from these three profiles that integration of exercise into the daily lives of people with diabetes is a challenge, and that general guidelines and recommendations by health care providers are a good starting point. Lorenzi also feels that health care providers should give detailed instructions regarding medication adjustments to reduce any possible risk of hypoglycemia. Successful integration of exercise and increased physical activity should also be reevaluated and adjusted to better allow patients to adjust their fitness goals and blood glucose targets.