Exercise is an essential part of any plan of care (9). It should be emphasized to all patients with diabetes that this is as important as the other aspects of care. It is something that is generally overlooked and not discussed in a busy office visit, but patients need to understand the importance of this aspect of diabetes management. Patients often have a misconstrued idea of what exercise is. They can incorporate exercise into their daily life. It does not mean they need to join a gym or jog every day, though this would be good. They can take the stairs instead of the elevator, park far away from the store or workplace so that they have to walk further, wear a pedometer to work and get up and walk periodically, walk for 10 minutes after lunch, go visit a coworker on a different floor or up the hall, stand up at every commercial on TV and do some jumping jacks. These are all small ways to incorporate exercise into daily routines.

Exercise training raises high density lipoprotein cholesterol, lowers blood pressure, and leads to a 20 to 40% increase in insulin sensitivity by enhancing insulin action in skeletal muscles (10). Therefore, all diabetic patients should be encouraged to engage in 30 minutes of modest aerobic exercise (such as brisk walking, aerobics, swimming, or bicycling) three to four times per week. The intensity should be gauged to produce an increase in pulse rate to 60 to 70% of maximum, which can be calculated as 220 minus age. This level of exercise is referred to as "conversational exercise" because it is not intense enough to prevent the patient from conversing with a partner during the workout.

Exercise usually lowers blood glucose levels. If someone is a real competitive athlete, glucose levels will go up during competition due to adrenaline being released during this activity. Many times, the same person will have a low glucose level at a practice but a high one at a game even in the same sport. It takes a lot of insulin dose adjustments before normal glucose levels are achieved with exercise. There are many ways to deal with this. First, do the exercise without changing anything to see what happens. Many people prefer to take their pumps off for exercise. This can usually be worked out if the sport is not too long, like baseball or cross country running. If the patient is on injections, it is more difficult to address, but a plan needs to be developed. This patient may need to lower the bolus prior to the previous meal or snack or he/she may need to decrease the long acting insulin during the sport season. This makes it difficult to figure out what to do if there is no exercise that day as long-acting insulins (Lantus, Levimir) last for several days so changing based on the same day simply does not work for the patient. He or she would probably need to increase the fast-acting insulin on off days to counteract high glucose levels.

For athletes competing in sports, it is advisable to remove the pump during the sport (if using a pump), but reattach it as soon as the sport is over and replace at least 1 hour of basal insulin as a bolus. This will keep the glucose from rising within the first hour after the sport is finished. The Diabetes Research in Children Network (DirecNet) studied this and found that if the pump was kept on at the usual basal rate, hypoglycemia occurred, but if it was removed, hyperglycemia occurred very soon after the exercise was completed (11). Therefore, to prevent the hypoglycemia during exercise, pump should be removed or basal decreased significantly, but insulin needs to be replaced soon after exercise to prevent hyperglycemia. Exercise also cause delayed hypoglycemia in most patients with diabetes. In order to prevent this, patients are instructed to decrease basal rate at bedtime to 70 to

80% of their usual dose for 4 to 5 hours. This prevents nocturnal hypoglycemia in these patients. It was shown by Bussau, et al., that a sprint at the end of practice or a game reduces hypoglycemia due to increase in catecholamines (12). Since many athletes do this as part of their sport, it is no wonder that they come off the field with extremely high glucose levels that need to be corrected. Sprinting does raise glucose and many sports require sprinting.

Health-care providers must recommend exercise to their patients. The success rate is not very good for patients continuing an exercise plan, but if it is not discussed, the success rate is even poorer (13). Exercise is extremely difficult to maintain as is diet but if patients are not encouraged, they surely will not see any necessity for it. It should be addressed at every visit as a part of the visit. Sometimes hearing things over and over does eventually make a difference to a patient. Even if the motivation wears off, the patient will usually follow a plan for a while and if they are seen every 3 months, they may have more time that they exercise than they do not exercising. In a study at the Joslin Diabetes Center located at the University Health Care Center in Syracuse, NY, patients were asked to develop their own meal and exercise plan. At 2 and 6 months respectively, 89% and 92% of the participants felt that they were following the meal plan either some or most of the time. One hundred percent of respondents were able to determine their own exercise plan, with 98% indicating they could adhere to the plan, and 85.7% felt that the new plan would be easier than previous ones. At 2 and 6 months respectively, 70% and 73% felt that they were following their exercise plan either some or most of the time. Individualized meal and exercise plans can be successfully created by the patients themselves (14). In an integrative literature review, Dr. Nancy Allen, examined the literature on diabetes research using social cognitive theory (15) to determine its predictive ability in explaining exercise behavior and to identify key interventions that enhance exercise initiation and maintenance. The results showed that a statistically significant relationship between self-efficacy and exercise behavior was found in correlational studies. Results from the predictive study support the predictability of self-efficacy for exercise behavior. Self-efficacy (16) was predictive of exercise initiation and maintenance over time. The evidence for successful interventions to increase self-efficacy and exercise behavior over time was inconclusive (17).

In conclusion everyone is in agreement that exercise is an important and even essential part of any diabetes management plan. It is also one of the most difficult parts of the regimen for patients to adhere to.

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