Richard Peng RCEP, HFS, MS, MBA, CDE provides some medical guidelines and considerations when recommending exercise programs for patients.

By: John Parkinson, Clinical Content Coordinator, DiabetesCare.net

Although exercise remains a vital part of helping people with diabetes (PWD) in their self-management, it is often under discussed by medical providers, usually due to a lack of training and professional experience. Still there are some reasons to consider getting actively involved in patients’ exercise programs. Helping to oversee an exercise regimen can not only help patients keep excess pounds off and maintain stable blood glucose, it might be a good way for educators to endear themselves even further to their patients in the process.

Richard Peng is a registered clinical exercise physiologist and a certified diabetes educator. He brings these two distinctive and unique skill sets together to counsel his patients in developing and overseeing their exercise programs while also caring for their diabetes.

Understanding that patient profiles come in many different forms, from the morbidly obese, to the young type 1s with insulin pumps, to the elderly with vision problems due to diabetic retinopathy, Peng begins by assessing patients’ medical and exercise histories as well as their goals. This way, he can identify where to start and what to be aware of with individual patients. 

Peng also points that it is important to start off small and easy, especially for patients who are either sedentary or morbidly obese, and that educators want to get them doing activities they enjoy and not make it another chore-like responsibility. These strategies can help keep up with patient compliance.

DiabetesCare.net sat down with Peng to discuss how fellow educators can begin to think about getting their patients started with exercise, some guidelines and metrics to consider for patients actively doing so, and how to encourage them to stay the course.

DiabetesCare.net: When talking to clients with diabetes and looking to have them exercise as part of the program, how do you begin? What type of clinical criteria do you use?

Peng:
When I talk to them, I want to find out what their goals are and what they enjoy doing. When it comes down to working with a patient and keeping them motivated you need to identify what they like to do. I also want to find out if they are engaging in any physical activity or have played any sports, because that gives me a base of where they are so I can appropriately get them started with their exercise. In my initial visit, I would have permission from their physician to engage in an exercise program or physical activity. I also want to find out if they have any limitations including injuries, comorbidities, and contraindications. I am approaching this appointment as health improvement—there are other health benefits from exercise in addition to improving blood glucose.

DiabetesCare.net:
Some people with diabetes are morbidly obese. Understanding there might be some limitations to this patient population, what type of exercises do you start with for people who might fall into this category?

Peng:
For this population, any activity that they can do safely is what we start with. There are a few different things these people can do. Walking is effective and one of the safest modes of exercise. They can also start off with strength training using light hand weights or their body weight as resistance. Another option is to use the pool for water aerobic classes or swimming.

It is also about finding the right exercise for the individual. For some people who are morbidly obese, walking might be tough on their joints. We might think about other exercises that are less weight-bearing like chair exercises where they don’t have to stand up but they are able to move their limbs. Any movement helps burn calories.   

DiabetesCare.net: Whether it be someone who is morbidly obese or even someone who has diabetic retinopathy are there any general limitations to exercise you consider in people with diabetes who have pre-existing co-morbidities?

Peng:
The two main things with PWD are knowing their glucose level and keeping it within an acceptable range, because any form of physical activity decreases their glucose levels. It can be dangerous for PWD who also have hypoglycemic unawareness to do physical activity.

DiabetesCare.net: As you want to make sure their blood glucose levels are not too high or too low, do you have a criteria for their blood glucose, especially when they are first getting started for how often they should be measuring their blood sugar?

Peng: Yes. Let’s say, for example someone starts walking for 15 to 30 minutes. I would suggest the person’s blood glucose be no lower than 120 and that the person always have a quick-acting carbohydrate with them whether it be a hard candy or juice, so that if they begin to feel hypoglycemic, they can just eat or drink what they brought. If they are exercising at a higher intensity or a longer period of time, then their blood glucose should be higher than 120.

DiabetesCare.net: When should you check your blood glucose in relation to exercise? 

Peng:
I counsel my patients to measure their blood glucose both before and after they exercise, as well as during if they are exercising for a long enough period. If they are exercising longer than a half hour, I would recommend they measure their glucose anywhere from 20 to 30 minutes into their workout, because when they are exercising their metabolism is quicker so their bodies use up their glucose more quickly. In the middle of exercise, you want to make sure it is not too low and your body is responding appropriately to exercise.  They should also check their blood glucose several times throughout the day they exercise because their metabolism continues to be elevated after they exercise for the next 24 hours or so.

DiabetesCare.net: For a diabetes educator who does not have any professional experience recommending exercises for patients or does not have access to an exercise physiologist, are there any particular professional resources online or elsewhere that fellow educators would want to consider looking at for assistance in helping patients with exercise?

Peng: One of the sites I refer my patients to is the National Institute on Aging, which is part of the National Institutes of Health. In particular, I suggest they download a book online, Exercise & Physical Activity: Your Everyday Guide from the National Institute on Aging, or they can order a free copy of the book. (People interested in ordering the book can go here to this website).

Another site I recommend is the AADE’s site. They recently came out with their 2011 position statement on diabetes and physical activity. As members of AADE, they can also access a number of resources including newsletters from their Physical Activity Community of Interest (COI) File Library.

At the end of 2010, the American College of Sports Medicine and the American Diabetes Association published a Joint Position Statement on Exercise and Type 2 Diabetes.

DiabetesCare.net: What are some of the metrics you use in assessing to see if exercise is helping your clients?

Peng: I check their A1c before they start exercising and then three to six months after they have been exercising.  While I do monitor my patients’ weight, I often ask them how they are fitting in their clothes and if they are fitting looser. With exercise, especially if they have incorporated strengthening exercises into their program, they might not see a reduction in weight as quickly as those strictly on a calorie restricted program because muscle is denser than fat. If they gain a little muscle and lose a little fat it may not show on the scale. And for patients who are trying to lose body fat it might be discouraging. I make sure my patients understand this. And for my patients who have hypertension, I monitor their blood pressure.

DiabetesCare.net: If you have someone who is sedentary or morbidly obese and they have not exercised in a while and they experience a strain or stress when they are doing exercise, when is a good measurement of when to stop and take a break?

Peng: When patients starting exercise, I always emphasize to them to work within their ability and what they are comfortable with because as they get healthier and stronger that intensity will become easier and they would be able to do more. They should not exercise and hold off on it if they have any pain or muscle injury, including a minor strain or sprain. Although the current general recommendation is exercise or engage in physical activity for 150 minutes per week, for patients who can’t do that, it can be very discouraging. I advise these patients to start out doing every other day and even 5 to 10 minutes is a good start.    

DiabetesCare.net: How do you keep people motivated to continue exercising, especially in the early going of a program when it can be especially challenging for people who may be sedentary?

Peng: It can be an eye-opener in doing something as simple as showing them their blood glucose reading after 15 minutes of exercise. Lots of times patients don’t know how effective physical activity can be in terms of glucose. And whether exercising at home or in the gym, I work with my patients to make sure it fits into their schedule and it is something that they enjoy.

Building a rapport with patients is also important. A number of patients have told me that knowing that someone cares enough to check on them periodically, helps make them feel more accountable and keeps them going. I also discuss what changes they can expect to their bodies during exercise, such as muscle soreness a day or two after their first exercise bout. All this can help my patients be more confident in their coach, thereby keeping them motivated. 

In the coming weeks, DiabetesCare.net will be including more stories about exercise, including discussing the collaboration between a trainer and a CDE and how developing a relationship like that can be another way to remain involved in patients’ fitness. 

Originally posted by DiabetesCare.net on September 9, 2011.