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Exercise for People with Type 2 Diabetes

By David Mendosa

Last Update: November 1, 2005

Three things help you control type 2 diabetes. The easiest is taking the medication your doctor prescribes. The hardest is your diet because of the never ending decisions about what, how much, and when to eat.

It’s the Deed
Not the Speed

Exercise is easier than diet, but more of a decision that taking a prescription. More and more doctors recognize that exercise is good medicine. Someone wrote recently that prescribing exercise along with medication is the coming thing. It isn’t — it’s already here.

Dr. Richard K. Bernstein, an endocrinologist in Mamaroneck, New York, wrote Dr. Bernstein’s Diabetes Solution and is known as the leading low-carb advocate for people with diabetes. He tells me that he already prescribes specific exercise to most of his patients. Another endocrinologist who regularly prescribes exercise is Dr. Alan Rubin in San Francisco. He wrote Diabetes for Dummies.

Why Exercise
Exercise makes you feel and look better. It takes glucose out of your blood to use for energy. It helps prevent heart disease, depression, and even some forms of cancer. If you do enough, it will help you to lose weight.

Being physically inactive is one risk factor for heart disease; diabetes is another. Risk factors are not something you want to collect. Once you have diabetes you live with it, but you can reverse inactivity.

Getting Started
A common recommendation is for your doctor to examine you before you start an exercise program. Certainly, a doctor should check out people with diabetic eye disease and blood vessel problems. But since it could be an excuse to postpone exercise, I wondered if everyone needs a checkup.

“I do think that the eye and vascular condition would warrant a special bit of advice,” Dr. J. Joseph Prendergast, an endocrinologist in Redwood City, California, told me. “But the rest would not.”

Dr. Rubin also tends to agree. “We all do some walking already,” he told me. “If all a patient is doing is walking, I don’t think [an exam] is necessary. The important thing is to start at a low level and build up. But if he or she wants to go from a sedentary lifestyle to vigorous exercise like mountain biking, jogging, or long distance running, it’s a good idea to get a physician’s okay.” You also need to start slowly every day. Gradually warm up for 5 to 10 minutes and likewise cool down.

People with type 1 diabetes, the American Diabetes Association's current position statement on exercise says, should avoid exercise if their levels are more than 250 mg/dl and they have ketosis — high levels of acidic substances called ketones in their blood - or if their level is over 300 even if they don't have ketosis.

Before strenuous exercise, it’s also a good idea to check your blood glucose and your feet for cuts or blisters. During exercise, stop immediately and take three glucose tabs if you feel an insulin reaction coming on. After exercising, check your level and feet again.

When you start exercising you need a good pair of shoes. For walking don’t wear running, tennis, or basketball shoes, because they don’t give you enough stability. Walking shoes give you more lateral support than other sport shoes. Try on different shoes at a well-stocked store. Flex your feet, wiggle your toes, and walk around until you find a pair that feels comfortable. Never count on breaking in uncomfortable shoes.

Take a big drink of water before exercising. A water bottle on your treadmill or in your fanny pack also makes sense.

What and Where
Walking or hiking is the exercise of choice for most folks. But neuropathy or other problems can make walking difficult for some people. They usually find that water aerobics and swimming laps is a great alternative.

But what if it’s too hot or cold or wet outside or takes too long to get to a place you like? Stay home and use a treadmill, a stationary bike, or a stair stepper. Last November some people with diabetes inspired me to buy a treadmill. I used it exclusively until it got warm enough here for me to go back to my favorite trails. I also got two 5-pound weights that I keep next to my easy chair and lift whenever I watch television.

How Easy, How Interesting
You know the old saying, “No pain, no gain.” You can forget it.

Your exercise program doesn’t have to be hard. A major study determined that you cut your risk of heart disease even if you do only light to moderate walking. The amount of time is more important than your pace. It’s the deed, not the speed. And you don’t have to do it all in one fell swoop.

Some people are out of shape because they think exercise is boring. Forget that too. The key is choosing something you enjoy. I think it’s easiest to be excited about what I’m doing when I’m walking a trail. There’s always something new, even if I have been down that path hundreds of times. Walking with a partner also keeps it interesting.

But even when you work out at home, you can make time pass quicker by reading a magazine, listening to music or a book on tape, or watching television. Alternatively, you can just use that time to clear your mind. Your exercise can simply be something you do for yourself on a busy day. But paradoxically by getting in a better mood, it can help others too.

Then, gadgets can make our daily workouts more interesting. Some people use pedometers to measure how far they walk. Others use heart rate monitors to make sure that their workouts aren’t too easy or too hard.

How Much
The controversy is how much exercise: 30, 60, or 90 minutes a day. In 1996 the Surgeon General set a low bar, a total of 30 minutes of moderate physical activity on most days of the week. However, the government’s current recommendation is up to 90 minutes of exercise most days of the week.

I wondered whether the new recommendation asks so much of us that we will just throw up our hands and sit on our behinds. Dr. J. Joseph Prendergast told me that he thinks we will. He quoted Voltaire, who long ago said, “the best is the enemy of the good.”

But Dr. Rubin doesn’t feel that the new government regulations are out of line. “There was a time when we thought it was unrealistic to ask people to stop smoking. Personally, I do at least 90 minutes of exercise daily and feel great as a result,” he told me. “The patients in my practice who do best with their diabetes are the ones who do the most exercise. Some of them told me it was impossible for them to lose weight. The only way I have been successful with them is when they have done several hours of exercise every day.” He points out a 2004 study that shows overweight people lose more weight the more they exercise — even without dieting.

I have noticed that after a two or three hour walk, I am actually less hungry than I normally am and eat less. That may be part of its weight loss charm. I know the conventional wisdom is that exercise is supposed to make you hungry, but it sure doesn’t work that way for me.

The Wisdom of Inefficiency
Maybe the young and the restless know something that most of us with diabetes don’t. I don’t mean the long-running soap opera of that name, but rather that physical inefficiency is a key to weight loss.

We gain weight when our energy intake is more than our energy expenditure. Exercise is the usual way that we think about how we expend energy. Another way that is just being studied is the routines of daily life. Dr. James Levine, a Mayo Clinic endocrinologist and nutritionist, calls this non-exercise activity thermogenesis or NEAT.

I always thought that fidgeting and tapping your foot and restlessness and pacing was a bad thing — a waste of effort. It seems that it’s not.

“People with obesity are tremendously efficient,” Dr. Levine told Denise Grady of The New York Times. “Any opportunity not to waste energy, they take. If you think about it that way, it all makes sense. As soon as they have an opportunity to sit down and not waste those calories, they do.”

That was me in spades. Before reading this, I prided myself on not wasting effort. I am now going to try to be physically inefficient.

The article by Dr. Levine and his associates, “Interindividual Variation in Posture Allocation: Possible Role in Human Obesity,” appears in the January 28, 2005 issue of Science magazine. An abstract is online.

Conclusion
We need a new mindset. Our ancestors didn’t call it exercise, but they walked for hours as they hunted for food. We no longer have to move around on our feet, so we invented something called exercise. When it becomes second nature to move around like our ancestors did, we begin to control our diabetes. 


This article originally appeared in Type 2 Life, Fall 2005.


    David Mendosa is a freelance journalist and consultant specializing in diabetes and lives in Boulder, Colorado. When he was diagnosed with type 2 diabetes in February 1994, he began to write entirely about that condition. His articles and columns have appeared in many of the major diabetes magazines and websites. His own website, David Mendosa’s Diabetes Directory, established in 1995, was one of the first and is now one of the largest with that focus. Every month he also publishes an online newsletter called “Diabetes Update.” Twice weekly he writes for his blog at http://blogs.healthcentral.com/diabetes/david-mendosa. He is a coauthor of What Makes My Blood Glucose Go Up...And Down? (New York: Marlowe & Co., August 2003, and second American edition coming July 10, 2006, and other publishers in the U.K., Australia, and Taiwan).


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