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ACSM'S Health & Fitness Journal:
doi: 10.1249/FIT.0b013e3182335360
DEPARTMENTS: Wouldn't You Like to Know

Wouldn’t You Like to Know

Bushman, Barbara Ph.D., FACSM

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Barbara Bushman, Ph.D., FACSM is a professor at Missouri State University. She holds four ACSM certifications: Program Director, Clinical Exercise Specialist, Health Fitness Specialist, and Personal Trainer. Dr. Bushman has authored papers related to menopause, factors influencing exercise participation, and deep water run training; she authored ACSM’s Action Plan for Menopause (Human Kinetics, 2005), edited ACSM’s Complete Guide to Fitness & Health (Human Kinetics, 2011) and promotes health/fitness at http://www.Facebook.com/FitnessID.

Q: MY HUSBAND (36 YEARS OLD) WAS RECENTLY DIAGNOSED WITH TYPE 1 DIABETES. HOW IS THIS DIFFERENT FROM TYPE 2 DIABETES? IS THIS DIAGNOSIS TYPICAL FOR SOMEONE OF HIS AGE? DOES HE NEED TO GO ON A SPECIAL RESTRICTED DIET? WE EXERCISE TOGETHER AND WONDER WHAT HE SHOULD INCLUDE IN HIS WORKOUTS? THIS DIAGNOSIS HAS BEEN RATHER OVERWHELMING FOR US AS A COUPLE, BUT WE WANT TO DEVELOP A PLAN TO MANAGE HIS DISEASE AND OPTIMIZE HIS HEALTH.

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A: Diabetes is a disease characterized by elevated blood glucose. According to the 2011 National Diabetes Fact Sheet, 25.8 million children and adults have diabetes in the United States, and in 2010 alone, there were 1.9 million new cases of diabetes (8). Although these numbers indicate the prevalence, your questions show how very personal each case is for individuals and families. You already have identified two important lifestyle factors to help manage diabetes — diet and exercise.

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TYPE 1 VERSUS TYPE 2 DIABETES

With regard to your first question, although types 1 and 2 diabetes both result in higher than normal blood glucose levels, the cause of each differs (3). Type 1 diabetes results when the insulin-producing beta cells in the pancreas are destroyed by the body. The trigger for this autoimmune response is still poorly defined (3). Insulin is required to help transport glucose from the blood into the cells of the body, so when the beta cells are unable to produce insulin, the glucose levels become elevated in the blood. Type 2 diabetes begins with insulin resistance, meaning the cells cannot properly use the insulin released by the pancreas (3). When cells are resistant to the action of insulin, glucose remains in the blood, thus resulting in elevated levels. Over time, the body’s ability to produce insulin also can decrease, contributing to high blood glucose (referred to as hyperglycemia). Risk factors associated with types 1 and 2 diabetes are found in Table 1.

TABLE 1: Risk Factor...
TABLE 1: Risk Factor...
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Type 2 diabetes is much more common than type 1 diabetes, about 90% to 95% of cases compared with about 5%, respectively (3). Type 2 diabetes is mainly found in adults (explaining the formerly used designation of adult-onset diabetes) but also can be found in youth — rare in those younger than 10 years (0.4 new cases per 100,000 annually), but somewhat greater rates have been identified in youth age 10 to 19 years (8.5 new cases per 100,000) (8). Most, but not all, individuals with type 2 are obese or have a higher percentage of fat in the abdominal region (3). Type 1 diabetes is diagnosed more typically in youth (formerly called juvenile diabetes) but, as you have experienced, also can be found in adults. Although the onset of type 1 diabetes often occurs early in life, half of new diagnoses are in those older than 20 years (9). People in their late 30s and early 40s also have a relatively high prevalence, although the onset often is not as abrupt as found in youth; this slow-onset adult form is referred to as latent autoimmune diabetes of the adult (9).

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NUTRITION FOCUS

Although weight loss often is a major focus for individuals with type 2 diabetes, good nutrition is important for everyone. Diabetes results from a breakdown in the link between carbohydrates consumed and the body’s ability to use carbohydrate for energy. Given the focus on carbohydrate (glucose), you might anticipate that a highly restrictive diet would be necessary. Low-carbohydrate diets (<130 g per day) actually are not recommended as a means to manage diabetes (5). Consider the following recommendations for management of diabetes (5):

* Include carbohydrate from fruits, vegetables, whole grains, legumes, and low-fat milk.

* Consume a variety of fiber-containing foods.

* Monitor carbohydrates (e.g., carb counting, exchanges, experienced-based estimation).

* Limit saturated fat to less than 7% of the total calories, minimize intake of trans-fats, and limit dietary cholesterol (<200 mg per day).

* Consume two or more servings of fish each week.

* Follow typical recommendations to consume 15% to 20% of total calories from protein.

Working with an endocrinologist, diabetes educator, and/or dietician will be important to individualize how to balance insulin therapy along with dietary and physical activity patterns. Each person is different and must learn to adapt to daily changes in how the body responds to activity, food consumed, and other situations like illness and stress. Two general ways to approach diet are the plate method and carb counting.

The plate method of meal planning encourages consuming foods in appropriate amounts by dividing your plate in half and then one side in half again (Figure 1); foods include nonstarchy vegetables, starch and bread, and meat or other protein in addition to a dairy item and fruit. This method helps to keep portions in check while also providing a balance of carbohydrates, fats, and proteins (6).

Figure 1
Figure 1
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Another commonly used method is to count grams of carbohydrate. Although carbohydrates can be in the form of starches, sugars, or fiber, the first two have the greatest impact on blood glucose levels. Although your diabetes care provider can provide specific targets, a typical starting point is about 45 to 60 g of carbohydrate per meal (6). Keeping carbohydrate intake consistent with regard to time and amount is helpful for anyone with fixed daily insulin (5). If using rapid-acting insulin or an insulin pump, then insulin doses can be adjusted depending on the content of the meal or snack.

The nutritional plan for individuals with diabetes reflects healthy eating patterns, rather than an oppressive, restrictive diet. Many resources are available to help manage the nutritional aspect of diabetes. The American Diabetes Association has a calorie and carbohydrate counting tool called MyFoodAdvisor (see www.diabetes.org/food-and-fitness). Also, the U.S. Department of Agriculture provides the nutrient content of a wide variety of foods at www.ars.usda.gov (then enter Nutrient Data Laboratory into the search box).

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EXERCISE AND DIABETES

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Exercise can help improve blood glucose levels as well as provide many benefits related to cardiovascular health, weight management, blood pressure, and cholesterol. Including exercise on a regular basis is particularly important as the effect on blood glucose control will be lost within days (10). Because of the relationship between diabetes and heart disease, there are situations in which having a cardiac stress test are warranted (see Box), and there may be other concerns, such as retinopathy, nephropathy, or neuropathy, that may need to be addressed with your diabetes care provider (4). Assuming appropriate medical clearance is in place, exercise should include a warm-up, conditioning phase, and then a cooldown.

Both cardiorespiratory (aerobic) exercise and resistance training are recommended, along with stretching to maintain flexibility (1,2). A general summary of exercise recommendations for individuals with type 1 diabetes is given in Table 2. A consistent exercise plan along with balanced food consumption and insulin doses will help to maintain appropriate blood glucose levels, not too low or too high.

TABLE 2: General Exe...
TABLE 2: General Exe...
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Exercise helps to move glucose into the cells. This is beneficial but also may result in blood glucose dropping too low (hypoglycemia), especially when combined with insulin. Some hints to help avoid hypoglycemia are as follows (2):

* Be consistent with carbohydrate intake related to the timing of your meals and exercise.

* Do not exercise at the time of peak insulin action.

* Maintain a regular time of day for your exercise.

* Monitor your blood glucose before and after exercise, and if a longer exercise session, even during — typically, the goal is to keep blood glucose between 100 and 250 mg/dL to help avoid both hypoglycemia as well as hyperglycemia.

The effects of exercise can affect blood glucose for up to 12 hours or more, so special care should be taken to check glucose levels if exercising later in the day (to avoid hypoglycemia during sleep). Having an extra snack may be necessary; such snacks should include both carbohydrate (15 g) and protein (7 to 8 g) (7).

When glucose levels are not under control, the liver’s production of glucose increases, potentially resulting in higher blood glucose levels during exercise (7). Although moderate-intensity exercise may reduce blood glucose by helping increase glucose transport into the cells, high blood glucose levels can occur after intense exercise (10). Thus, hyperglycemia before exercise may require exercise to be delayed or the intensity decreased to avoid ketoacidosis (reflecting fat use and the resulting production of ketones), which is a serious medical condition (10).

Blood glucose levels should be monitored before any exercise session. See Figure 2 for a decision-making flow chart. If glucose levels are too low, some carbohydrate should be consumed before exercising. If glucose levels are high, then it will become important to reflect on how you are feeling and to check for ketones in the urine (done with a simple at-home test kit). Work with your diabetes care provider to develop your individualized plan of action regarding adjustments in food consumption and insulin doses when planning for exercise.

Figure 2
Figure 2
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Some other factors to consider, specific for individuals with diabetes are as follows (4):

* Wear polyester or cotton-polyester blend socks to prevent blisters.

* Keep feet dry to minimize trauma to the feet.

* Wear proper footwear for the activity.

* Maintain proper hydration (dehydration can affect blood glucose levels).

Wearing a diabetes identification bracelet or shoe tag is highly recommended. In cases of hypoglycemia, individuals can become confused and even lose consciousness. Thus, it is important for others to be informed, so they can take action if needed.

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CONCLUSION

Although your husband’s diagnosis of diabetes was a shock, you are right on track with a focus on including physical activity and nutrition as tools in managing the disease, as well as in promoting overall health. Each day will present new challenges, but monitoring blood glucose and continuing to work with your diabetes care provider will result in good health now and into the future.

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References

1. American College of Sports Medicine. ACSM’s Guidelines for Exercise Testing and Prescription. 8th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 380 p.

2. American College of Sports Medicine. ACSM’s Resource Manual for Guidelines for Exercise Testing and Prescription. 6th ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2010. 868 p.

3. American Diabetes Association. Position statement: diagnosis and classification of diabetes mellitus. Diabetes Care. 2010;33:S62–9.

4. American Diabetes Association. Position statement: physical activity/exercise and diabetes. Diabetes Care. 2004;27:S58–62.

5. American Diabetes Association. Position statement: nutrition recommendations and interventions for diabetes. Diabetes Care. 2007;30:S48–65.

6. American Diabetes Association Web site [Internet]. Alexandria VA: American Diabetes Association [cited 2011 May 10]. Available from: www.diabetes.org/food-and-fitness.

7. Beaser R, Horton E, Mullooly C. Physical activity for fitness. In: Beaser RS, editor. Joslin’s Diabetic Deskbook, 2nd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2007. p. 127–152.

8. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.

9. Khardori R, Bessen HA, Hussain AN, Schraga ED, Vincent MT. Type 1 diabetes mellitus. Medscape Reference. [Internet]. May 12, 2011 [cited 2011 May 20]. Available from http://emedicine.medscape.com/article/117739-overview#a0156.

10. Steppal J, Horton E. Exercise in patients with diabetes mellitus. In: Kahn CR, Weir GC, King GL, et al. editors. Joslin’s Diabetes Mellitus. Philadelphia (PA): Lippincott Williams & Wilkins; 2005. p. 649–57.

© 2011 American College of Sports Medicine

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