Hello everyone. So, I would like, I am Dr. Shivani Siddhana from AIIMS, Bathinda, Punjab, India. So, I would like to first of all thanks endocrine society for giving me this opportunity to be part of this educational webinar series. So, today we will discuss diabetes and physical activity with a comprehensive approach. I have no disclosure, no, no conflict of interest. So, we will discuss the physiological effect of exercise, what should be there in the prescription of while prescribing the exercise for the patient with the diabetes, including the guideline recommendation for the exercise, what are the risks of exercise and what are the special considerations in different diabetes subsets. So, first of all, we will discuss the physiological effect of exercise. Before starting, we should know what is physical activity and what is exercise. Physical activity is a general term that includes all the movements that increase the energy use, while exercise is a more specific form of physical activity that is structured and designed to improve the physical fitness. So, exercise is basically structured and designed physical activity. So, every kind of exercise improves the glucose level, decrease the blood pressure, improves the activeness, has good effect on the lipids and improves the physical function, depression, quality of life and many more metabolic and other benefits. Starting even breaking up the prolonged sitting, increasing the intensity up to increase step count and moderate to vigorous physical activity and resistance training all have the metabolic benefits, but moderate to vigorous physical activity improves these all parameters, while the strength training also improves the insulin resistance, HbA1c and more the physical functions. The exercise should be done along with the adequate sleep quality and timing. So, whenever a person start doing exercise in the metabolic benefits starts right away because the glucose uptake is increased in the contracting the contracting skeletal muscle. So, increased glucose uptake and glucose utilization by the acting skeletal muscle leads to increased glucose output by the liver as well as increased triglyceride mobilization by the adipose tissues and to supply the adequate amount of energy substrate there is increase in the cardiac output and vascular permeability increases and there is increased delivery of oxygen and blood glucose in oxygen and energy substrate to the contracting muscle. So, all of these are accompanied by decrease in the insulin and increase in the glucagon levels. So, there is active mobilization of energy substrates from the energy stores that is liver and adipose tissue to the contracting skeletal muscles that use the excess energy. So, when the person do exercise for long duration this there is there are metabolic adaptation that happen in the body that will lead to increase in the mitochondrial density morphology and increase in the mitochondrial density in the skeletal muscles and also there is increased oxidative capacity of mitochondria. It also decreases the insulin resistance at the skeletal muscle level because of the decrease in the lipotoxic lipid content. It also decrease the insulin resistance at the level of liver and the adipose tissue and also there is increase in the gluconeogenesis glucose output uptake by the liver and the maximum oxygen capacity of the cardiac muscles increases. There is decrease in the resting heart rate and decrease in the blood pressure. The vascular there is also increase in the blood flow to the capillary density in the skeletal muscles. So, overall there is increase in the beta cell function. This leads to increase in the aerobic capacity of the person and also there is decrease in the insulin resistance and improve metabolic parameters. It all this all culminate to decrease the risk of type 2 diabetes improvement in the diabetes control, decrease in the NAFLD scores, improve cardiovascular fitness and also decrease the cardiovascular diseases. It leads to decrease in the mortality rate. So, exercise is very important part of treatment recommendation of diabetes. So, we should know there are different type of exercise categorized basically on the basically on their metabolism and how they are using the energy substrates. They are the most commonly they can be divided into broadly they can be divided into anaerobic exercises and aerobic exercises. So, anaerobic exercises as we will discuss in few further slides will lead to substrate metabolism in the anaerobic manner that is without oxygen when the aerobic exercise utilize the substrate energy substrate aerobically. So, not only during the period of exercise the body's metabolism changes for a long duration and the muscle glycogen, liver glycogen and the muscle as well as liver triglycerides, triglycerides from the non-esterified fatty acid from the plasma and the fatty acid released from the adipose tissues are used for the restoration of the energy stores as well as the muscle repair for long longer duration of time. Depending upon the intensity of exercises exercise the muscle glycogen, muscle triglycerides, plasma free fatty acid and plasma glucose are utilized in a different proportion. Higher is the intensity of exercise more is the utilization of muscle store glycogen. So, as we have discussed the exercise increase the energy utilization by the glucose as the ATP during exercise ATP is converted to AMP. This AMP activates the AMP kinase that leads to mobilization of gluteal receptors into the skeletal muscle membrane. So, this glute 4 increase the glucose uptake in the skeletal muscle in insulin independent manner. So, the glucose uptake remain elevated from 2 hours to up to 48 hours. So, we advise that if a patient should not keep a gap of more than 2 consecutive days between the 2 sessions because insulin sensitivity because glucose uptake is increased in the skeletal muscle up to 48 hours in a 1 bout of after a 1 bout of exercise session. So, even low intensity exercise when done for more than 60 minutes leads to increase in the glucose uptake and decrease in insulin resistance for up to 24 hours. But the different exercises when we talk about in acute manner the different exercise response of blood glucose to different exercises different because in anaerobic exercises the energy metabolism is in the anaerobic manner. So, it will lead to generation of more lactate. Lactate will lead to decrease in the uptake of glucose from the blood to the skeletal muscle. It also release the stress hormones because in anaerobic exercises the energy these are the exercises in which the exercise is done in a very short duration of time and there are these are the intense exercises. So, they release the stress hormone they lead to increase in the stress hormone that will also lead to hyperglycemia. So, anaerobic exercises are associated with the hyperglycemia while the aerobic exercises because of increased glucose utilization are associated with the hypoglycemia after the exercise. So, while prescribing the exercise we should know what are the types of exercise. There are mainly three type of exercises aerobic exercise resistance training or anaerobic exercise and flexibility or balancing exercise. So, first we talk about before prescribing any kind of exercise we should know that all the we should follow the principle of FITVP that is we should include in our prescription what should be the frequency of exercise where should be intensity of exercise what is the type of exercise for what time or duration the patient should do exercise what is the overall volume of exercise per week or in a particular duration of time and how the patient should progress to the next level of exercise. So, first talking about the aerobic exercise these are the prolonged rhythmic activities using the large muscle groups the muscle group activated by this type of exercise rely on the aerobic metabolism to extract the energy in the form of ATP from mainly carbohydrate fatty acid and amino acids. So, the benefit of aerobic exercise as we have discussed it increases the insulin sensitivity, it increases the mitochondrial density, it increases the oxidative enzyme levels, it has it leads to improvement in the cardiorespiratory functions. So, it improves the lung functions, improves the cardiac output as well as immune functions and it is good for the metabolic health. So, aerobic exercise should be prescribed for at least three to seven days a week and there should be no a gap of no more than two consecutive days between the exercise as we have discussed because of increased glucose uptake up to 48 hours in the skeletal muscles and they should be they should then patient with type 2 diabetes should do about at least 150 minutes per week of moderate to intense vigorous intensity exercises. So, if the however the if the patient is young and the he can he or she can run at a pace of nine around 9.7 kilometer per hour that for 25 minutes then he can choose for around 75 minutes per week of vigorous activity this much amount of vigorous activity that that means three times a week to produce a similar cardio protective and metabolic benefits and the progression should be according to the different according to the patient each and every patient is different but if the patient is totally inactive they can start with the low intensity and move on to the moderate and vigorous intensity they can ignition can follow the rule of 10 while prescribing that is 10 percent increase in the intensity or duration of exercise every 10 days or every seven days depending upon the patient's requirement. So, gradually they can move on to the vigorous intensity exercise or if the patient's condition allow the HIIT that is high intensity interval training can also be recommended. So, the exercises that included in the aerobic exercises are the one that increase the breathing rate and that increase the heart rate of patient in a and the muscle use the glucose in an aerobic manner that is it can be social playing it can be jumping it can be using exercise using the rope it can be cycling dancing walking jogging running swimming these are the all are the type of aerobic exercise and these recommendation are the American Diabetic Association even NICE UK even Diabetes Canada all the guidelines recommend around 150 minute per week of moderate to vigorous intensity we will discuss in the further slides what is moderate to vigorous intensity exercise. So, this is the aerobic exercise now moving on to the anaerobic exercise. Anaerobic exercises are the intense physical activities of short duration. So, they are these exercises are fueled by the energy source within the contracting muscle that is already stored muscle glycogen or the is used for the as a energy source and it is used in a independent manner of that is in oxygen independent manner. So, these are the metabolized by the anaerobic metabolism. So, the what exercises come in this category. So, the exercises using the resistant band free weights or with the machines or the body weight exercises or even the sprint that is these are the exercises that comes in the category of anaerobic exercise apart from the metabolic benefits that there is a gain in the lean body mass with these kind of exercises. So, in the patient with the sarcopenia these exercises should be a part of their exercise prescription and they even everyone every patient with the type 2 diabetes without complication that we will discuss further should be prescribed the anaerobic exercises also to gain the skeletal muscle mass to prevent the sarcopenia is related to decrease decline in the muscle mass and to improve the bone mineral density. So, it improves the strength of patient and physical functioning of patient and also mental health how much anaerobic exercise is recommended and that that it is recommended that patient should do at least 8 to 10 exercises with completion of 1 to 3 sets of 10 to 15 repetitions to near fatigue level per set and it failure but it should be to near fatigue level and this should be done at least 2 to 3 non-consecutive days per week and if the patient is doing exercise in a moderate intensity then 15 repetition of exercises should be done maximum and if the patient is doing it a in a vigorous intensity then 6 to 8 repetitions should be done and the progression should be by the can be in a three manner first to increase the weight per set then to increase the number of sets and then to increase the training frequency. So, these are the anaerobic exercises and next is the flexibility or balancing exercises the it includes stretching that can be static or dynamic stretching and balancing exercise that is practicing on the one leg or using the balancing equipment or it can include the tai chi or yoga or other kind of stretchings. So, basically it should be prescribed especially in the older group of type 2 diabetes or other type 1 diabetes patient. So, because it improves the balance it improves the gait and it significantly decrease the risk of fall by around 30 percent it increase the flexibility and increase the range of motion of the joint. So, they should be done at least 2 to 3 times a week and the stretch should be done up to around 10 to 30 seconds. Yeah, there should be 2 to 4 repetition of each exercise and this stretch should be done to a point of tightness or slight discomfort but not to the point of pain. So, they can progression can be in a gradual manner to increase the duration or to increase the frequency duration of balancing exercise or to increase the frequency of exercises over time. So, in special situations suppose we are prescribing the exercise in a young type 2 diabetes patient or in the children and adults with the type 1 diabetes patients then the they should be recommended to do at higher at a higher duration that is around 60 minutes per day of moderate to vigorous intensity aerobic exercises is recommended and vigorous muscle strengthening or bone strengthening that is anaerobic exercises are recommended for at least 3 days a week and in the pregnant female they should be recommended to do at least 20 to 30 minutes of moderate intensity exercise on most of the day for all days of the week. So, it is not that the one exercise is a completely aerobic or completely anaerobic exercise they there are it is categorized based on the majority of the muscle energy substrate use majority of the pathway which the energy substrate are used and for example, cycling has major majority of aerobic component but some of the anaerobic component also and dancing has aerobic component as well as balancing component also. So, these things also should kept in the mind. Now, we will discuss what should be the intensity of exercise if we prescribe higher intensity of exercise there is increased risk of cardiovascular mishappenings for example, they can there can be increased risk of arrhythmias there can be increased risk of hypertension and hypotension post or during the exercise period so there can be increase or the precipitation of myocardial infarction there can be increased chances of musculoskeletal injuries during the exercise the patient will not if the patient is not used to then the patient will not be having that much compliance if we start with the higher intensity exercise so appropriate intensity according to the each and every patient should be advised initially so how we can measure the intensity of exercise so American College of Sport Medicine has given a different methods to measure the intensity of exercise we can measure the intensity of exercise based on the percentage of heart rate result or percentage of heart rate max maximum heart rate or by the metabolic equivalence or by the rate of perceived exertion and anaerobic exercise we can measure the intensity by percentage of RM so if the patient is if there is facility of doing exercise test exercise stress test then oxygen can oxygen oxygenation capacity that is vo2 can also be measured while doing the exercise so based on that also we can prescribe the exercise intensity so for example how we can prescribe according to the HR max that is heart rate max or HRR so we can calculate the maximum heart rate on the stress exercise test also but we can also calculate based on the patient's age and by the formula of classical formula of 220 minus age but this classical formula used can underestimate the maximum heart rate in the patient who are less than 40 years and it can overestimate the maximum heart rate in the patient who are more than 40 years of age so more accurate formula given by the challenge is 206.9 minus 167 into age so this by this we can calculate the maximum heart rate of that patient and if the you want to prescribe the moderate intensity exercise we can ask to keep the around 74 to 84 percent of the maximum heart rate when it is achieved we can say the patient is doing the moderate intensity exercise so the in the smart watches also we can get we can ask the patient to monitor their heart rate or they can monitor the heart rate by any of the different means so the other more more appropriate method is the heart rate reserve method so in which the baseline heart rate that is heart rate at rest is subtracted from the heart maximum heart rate and according to and from which the intensity of exercise can be derived for example if the patient's baseline heart rate is 80 beat per minute and the maximum calculated or measured heart rate is 170 beat per minute and if we want to prescribe the moderate intensity exercise that is 40 to 60 percent of the heart rate reserve then we can calculate the heart rate reserve that is 160 170 minus 80 that is the 90 beats per minute and 40 percent of 90 and 60 percent of 90 is calculated or added to the base their heart rate at rest to get the target heart rate range so we can ask the patient to do exercise and keep the watch on the their heart rate and it should be if it is between the 116 to 144 beat per minute then he is doing the moderate intensity exercise so this is another method of prescribing the intensity of exercise so if it is still not available then we can advise them simple task task test that is if the patient can sing or whistle while doing the activity then he is doing the low intensity exercise however if we can talk but not sing during the activity then he is doing the moderate intensity activity and he if he will not be able to say more than a few words without pausing a breath that is he is not able to complete a whole sentence without getting breathless then he is doing the vigorous intensity activity. So, this is the simple clinical method of measuring the exercise intensity and other simple method is the Borg scale of rate of perceived exertion and the Borg scale of rate of perceived exertion start from the number 6 to number 20 and while it is basically how the patient is perceiving the intensity of exercise and scale 6 if we choose the number 6 that means he is not exerting at all and if it chooses the number 20 that means he is doing maximum exertion. So, this 6 and 20 corresponds to initially when they give this number this correspond to the heart rate of 60 and 200 in a individual of 30 to 40 years. So, it many studies have shown the good correlation of Borg scale with the exercise intensity measured by the other methods and the modified Borg scale is the start from the scale of 0 to 11 and it is similar to the visual analog scale or Likert scale that we used in the pain in measuring the intensity of pain. So, it is from the if we if the patient chooses the score 0 to if give the score 0 to the activity performed that means he is not having much exertion while he is feeling very strong if he gives the maximum number. So, this is also another method of measuring the intensity. Other method is simple walking speed can be guide to the exercise intensity measurement if the if the person is moving around a speed of more than 4 miles per hour then it is considered as a very brisk walk brisk walking and if it is if the person is moving between 3 to 4 miles per hour then it is fairly brisk. So, the walking speed also guides about the intensity of exercise. The another method is metabolic equivalence. Metabolic equivalence is basically energy cost of human activity. Suppose one is sitting quite comfortably not doing anything that means is consuming at about 1 kilocalorie per kg per hour and it can also be defined in the form of oxygen uptake of around 3.5 ml per kg per minute. So, the ratio of metabolic rate to resting metabolic resting metabolic rate is considered as a metabolic equivalent. So, different activities have been given the different metabolic equivalent score. So, like slow walking, cooking, gardening, doing household activities are light intensity activities and they are even metabolic equivalent of 1.5 to 2.9 and moderate intensity activities like painting a wall, vigorous cleaning are given metabolic equivalent of 3.5 to 5.9 and if it is more than 6 that means the patient is doing vigorous activity jobs like he is doing laborious jobs or doing the weight lifting or cycling at a speed more than 10 miles per hour or running at more than 4 miles per hour. So, patient can be shown a chart of different activities with the equivalent metabolic equivalent and he can choose the different activities to perform and get to know about the intensity of exercise. So, few words about the resistance training how the patient should be practically advised by as per the American College of Sport Medicine guidelines that they say that the every patient should be should do at least two to three whole body sessions of longer duration per week or the they can be split up into the upper body exercises and lower body exercises and in increase the number of days of exercise. So, regardless of which approach is used single muscle should be rested for at least 48 hours between the two sessions and a resistance that allow 8 to 10 repetition should be performed at each set and whenever the patient feel fatigue this should be the intensity of exercise or the maximum strength that is 1RM. 1RM is basically resistance maximum that is the one maximum amount of the weight that with which the patient can do that exercise in the proper form is 1RM and person should if person is choosing 60 to 80 percent of RM then it is a proper resistance that is moderate intensity and the patient can do mostly 8 to 10 repetition per set initially and which can progressively be increased and the progression overload principle is first you have to increase the resistance or add on the more weight and then to increase the more repetition per set but not to the more than 12 repetition and then to increase the frequency of doing exercise in that particular muscle group per week and the proper care should be taken the technique is proper breathing pattern should be proper that involve exhaling during the lifting phase and inhaling during the lowering phase so the components of exercises should be first the patient should do warm-up then is the conditioning or the proper exercise phase then the cool down and stretching has is then they can do stretching exercise so why warm-up phase is required and what are the what should be done in a warm-up phase the 5 to 10 minute of low to moderate intensity aerobic exercises should be done and it will lead to increase in the body temperature and it will lead to decrease in the muscle stiffness and it will also lead to in slow transition of the metabolism that allow the body to adjust to the changing physiological biomechanical and biologic demands so it is very important to do warm-up warm-up before doing the exercise and patient should be advised to do warm-up to decrease the chances of injuries and cool down phase is also very important in this also an aerobic exercise should be done of low to moderate intensity for 5 to 10 minutes because cool down phase will allow to a gradual recovery of heart rate and blood pressure so it will decrease the risk of arrhythmias and hypo and hypertension post exercise so cool down phase is also very important and the it will also allow to allow the removal of metabolic product and products from the muscle and it leads to decrease in the muscle soreness post exercise so patient should be advised to do proper warm-up and cool down phase while doing the exercise and then we know a high intensity interval training is very good form of exercise and they can it include the exercises of high intensity alternating with the low intensity exercise or the phase of passive recovery that is phase of rest in between the periods of high intensity exercise so high intensity exercise should be done alternating with the low intensity exercise and it is a time-efficient modality for the persons who doesn't have much time to do exercise it has definitive benefit on the reduction in Hb1c and BMI it reduce the insulin requirement it has cardio metabolic improvement in the cardiovascular cardiometabolic risk profile and it improves the fitness level so there are two methods in which it can be done one it can be done in one into one is to one interval workout or it can be done then as a sprint interval method so in one is to one workout in in this the high intensity exercise of around three to four or five minutes can be chosen and equal time should be given for the recovery and meanwhile in the spring interval method 13 to 30 seconds of sprint or full and a pull-out workout a pull-out effort should be put on and followed by the 4 to 4 5 around 4 minutes of recovery so these exercises they are repeated for around 3 to 5 times so as we know these exercises use a high amount of energy so the base fitness level should be achieved by the patient before starting the high intensity interval training that is they should be able to do at least they are should they are they should be used to do at least through three to five times of moderate intensity aerobic exercise for about one month before starting the high intensity interval training so as these are very exhaustive sessions so and long recovery period is needed so while prescribing the high intensity exercise to those who are not used to this should be prescribed once in a week initially and then later on and the patient's fitness level increases the number of sessions per week can be increased so this meta-analysis recently published in 2016 has shown that high intensity interval training improves the has more beneficial effect in the HOMA IR and HB1C of patients and there are comparable comparable decline in the improvement in the fasting blood glucose level as compared to the other exercise modality of moderate intensity exercises aerobic exercise it improves the cardiomyocytes oxygen capacity and there are definitive benefits in improving the insulin resistance and oxygen carrying capacity and so it is highly beneficial for the persons who have time constraints so when the exercise that another portion the patient asked while while when we talk about exercise that when exercise should be done whether it should be done in the morning or in daytime period afternoon evening period so this meta-analysis was published recently in 2020 and it has shown that many studies have been conducted in to find out the answer to this question but the inconsistent findings have been there in the different studies but ultimate meta-analysis results shown has shown that the fasting exercise would lead to significant and consistent reduction in the mean 24-hour glucose level while afternoon exercise didn't the one possible explanation is that in the absence of exogenous fluids the fasting exercise rely on the endogenous fluid that is the intramuscular lipids and glycogen that this the changes of that may favor the increase in the insulin sensitivity however other other school of thought other studies has shown that the vigorous exercise may benefit in the afternoon especially when done in the afternoon because it correspond to the skeletal muscle metabolism clock so it will lead to it has they have shown that it will lead to better body composition if the patient do exercise during the afternoon period so but the bias is that if the glucose or fasting insulin are tested and after x afternoon session then it will be after 12 hour of exercise and if it is done after morning session then it will be 24-hour post exercise so there can be some bias in with regard to this however late exercise done in the patient with the type 1 diabetes predispose them to the nocturnal hypoglycemia so type 1 diabetes patient should do morning aerobic exercise in the fasting state as post meal exercise also lead to increased risk of hypoglycemia which we will discuss further so morning session is good for the persons who have later day responsibilities related to work or family and evening exercises are good for also good for the persons who are late chronotype at it will has it will help them to shift their chronotype at a earlier time so not a single time of exercise is good for everyone so the exercise should be described based on the suitable routine to the timing that is suitable to the routine to the patient and at that time the patient should be free mentally and he can do consistently the exercise so it's not that if he is doing the exercise in the evening and he is busy and it will he will not be consistent with the exercise so whether the exercise should be done pre-meal or post meal so if the exercise is done between the pre-meal period it will lead to decrease in the pre-meal blood glucose level and it will increase the post meal insulin sensitivity okay while when the exercise is done in the post meal period so it will lead to increase uptake of the glucose in post meal period so it will limit the postprandial rise in the glucose level so both of the timing are good but in the patients okay equally good but in the patients who are on the insulin or brandial insulin or who are taking the insulin secretor works and the when the exercise is done in the post meal period so at that time there will be active insulin in the body that is called as insulin on board so it will lead to increased chances of hypoglycemia at that time so the patients with type 1 diabetes or the patients who are on the brandial insulin should avoid doing exercise 2 to 3 hours post meal and they can be done in the pre-meal or up in the post absorptive phase that is after 2 to 3 hours of taking the meal so if the patient is totally not doing exercise and there is not fit to do that the exercises the every kind of physical activity has the beneficial effect on the metabolism starting from the sitting or breaking up the prolonged sitting to the stepping all these have the beneficial effect on the metabolism but this should be prescribed apart from the proper moderate to intensity vigorous moderate to vigorous intensity aerobic exercise and resistant training exercise and good sleep quality and timings so what about the step counts the idea of 10,000 steps per day doing 10,000 steps per day came from the Japanese tradition and so but it has been found that doing 10,000 steps per day is equivalent to energy expenditure of around 300 to 400 kilo calorie per day depending upon the different body sizes and while if when the patient is prescribed 30 minutes of moderate intensity physical activity it is equal to around 150 kilo calorie per day people have done studies to find out whether the 10,000 step per day is good for the patient it has been found that around 73 percent of participants recalled a minimum of 30 minutes of moderate intensity activities in those days they have completed the 10,000 steps while it was found in another study that prescribing 30 minutes walk only complete around in only around 50 percent of patient only achieve the 10,000 steps per day so it is still not a universal goal based on the step count the activities has been patient's physical activity level has been defined if the patient is doing around less than 5,000 steps per day then it's considered as sedentary and if it's doing if she is doing more than 12,500 steps per day then it's considered as a highly active and also based on the steps doing steps per minute there the walking speed has been defined that is more than 100 steps per minute then the that means the patient is doing a brisk walk so it is a useful guide to do to have the appropriate physical activity level so it has been found that there is a if the patient increases the 10,000 around 10,000 steps per day that decreases the risk of 6 year risk of diabetes by 2 to 3 percent it has also seen that when we ask the patient to use the step counter then it increases the physical activity level of patient to a significant manner so it is a simple method to motivate the patient to do physical activity and also alongside with the prescribing the intensity of exercise in a another manner also another alternative method also so it is simple it is easy to check by the patient and it provide a concrete goal to the patient and it help to promote their behavior change but there are some limitations that it needed it requires an equipment and it's also not sensitive to the non-ambulatory activities like cycling swimming weight training in which the hand movements are not there though so so the steps will not be counted in these moments until now we don't have a universal step goal so another method to improve the physical activity of the patient is to break the sedentary time so long sitting should be avoided and they should be interrupt the patient should be if possible the patient should do a light activity every 20 minute every 30 minutes or they can be advised to do 15 minutes of work in the post meal period if he is not on if the patient is not on the insulin or insulins it goes so long-term health benefits are still not known so these break in the sedentary time is should be recommended along with the structured exercise so this studies the studies have clearly shown this study also has clearly shown that the when the patient were and were advised to do that low intensity walking or simple resistance activity every third for three minutes every 30 minutes then there is definitive improvement in the post-pandemic glucose insulin c-peptide and triglyceride level up to seven hours so what are the possible risk of exercise so that should be kept in mind while describing the exercise there can be hypoglycemia or hyperglycemia depending upon the type of exercise and duration of exercise there can be musculoskeletal soreness of injury depending upon the based on the intensity of exercise they can be there can be precipitation of enzyme or myocardial infarction there can be damage to the foot especially if there is neuropathy or if there is already patient has ulcer or they can be worsening of already existing retinopathy so we will discuss these risks and how we can minimize these risks so hypoglycemia can be due to the insulin on board before the patient is doing the prolonged exercise without having a proper carbohydrate need while the hyperglycemia can be due to high intensity of exercise anaerobic exercise or due to the stress when the exercise is done in the stress period or during the dehydration or proper amount of the anti-diabetic medication has not been taken or the patient has not taken the insulin properly so the this is this is a diagram showing how the glucose level changes with the different kind of exercise in a constant aerobic excess in after constant aerobic exercise like after walking or after doing cycling there is decline in the blood glucose level depending upon the intensity of exercise while the patient if is the patient is doing high intensity exercise over short period of time whose patient is doing a sprint then there is rise in the blood glucose level due to increase in the catecholamines as we have discussed while if the patient is doing high intensity interval training that is doing high intensity exercises along with the low intensity or recovery period, then there are not much fluctuation in the blood glucose levels and if the patient is doing resistance exercises, then there is rise in the blood glucose levels. So, the explosive exercises or the anaerobic exercises on very high intensity sprints can be done before or after the aerobic exercise that will lead to decrease in the risk of hypoglycemia. So, the factors affecting the hypoglycemia are most of the factors we have discussed. So, the hypoglycemia awareness should be checked by the gold score or class gold score. If the patient has score of more than 4 that means the patient has impaired hypoglycemia and awareness. So, these patients are at a high risk of hypoglycemia or if the patient has serious hypoglycemia in last six months that means the patient is having high risk of hypoglycemia or if the patient is using cgm and the time below range is more than 8% that means the patient is at a high risk of hypoglycemia. So, this kind of patient should be guided in a proper manner because they are high risk of developing hypoglycemia. They should be advised to check all the patients on insulin, should be advised to check the blood glucose before starting the exercise or those who are at high risk of hypoglycemia should be advised to check the blood glucose before starting the exercise. If the blood glucose is less than 90 they should take the really digestible fast-acting carbohydrate around 15 to 30 gram before starting the exercise and if the exercise is prolonged for more than one hour then they should take take around 0.5 to 1 gram per kilogram of carbohydrate based on the blood glucose test. So, if the blood glucose is between 90 to 150 then they should start consuming excess carbohydrate at the onset of most of exercise depending on if they are doing it they are planning to do exercise for more than 45 minutes but if the exercise is brief in duration that is less than 45 minutes or 45 to 30 minutes then there is no need of additional carbohydrate. Similarly, if the patient is having blood glucose level of 150 to 250 milligram per deciliter then they can initiate the exercise but they should carry the carbohydrate with them if the blood glucose falls to less than 150 then they should consume that carbohydrate or every hour they should consume some amount of carbohydrate. If the blood glucose is more than 250 then before commencing the exercise they should check the their ketone levels and if it if there are positive tones of moderate to large amount then the exercise should not be performed and the appropriate measure should be taken to decrease the ketone level and healthcare health their physician should be consulted they should they should be advised to consult their physicians and if they are planning to start mild to moderate and in they can initiate mild to moderate intensity exercise without consuming the extra carb and while they should avoid the high intensity exercise at as it leads to increase in the further increase in the blood glucose levels and if the blood glucose is more than 350 if the ketones are positive then they should not do exercise if the ketones are negative and then they should take the correction bone correction insulin dose that should be 50% of their correction dose and and they should also avoid the high intensity exercise that this lead to increase in the hyperlipidemia so this is the general guide for the type 1 diabetes patients how they can choose to have exercise carbohydrate starting from before doing exercise up to the post exercise period if the blood glucose is less than 126 they should consume around one third 15 to 30 gram of carbohydrate before starting the exercise and if it is more than 180 they can delay the carbohydrate consumption if they are planning to do exercise for less than 45 minutes then the carbohydrate should be taken at least 15 to 30 minutes before commencing the exercise if they are planning for long exercise the carbohydrate should be taken one hour before the starting exercise so the insulin dose should be reduced the basal insulin rate should be decreased by the 50% and during exercise at every one hour they should consume around 30 to 60 gram depending on the patient's blood glucose level but if the patient require higher amount of carbohydrate then the glucose fructose ratio should be 2 is to 1 and during post exercise period also they should consume every two hourly around 1.1 to 1.5 gram of carbohydrate per kilogram carbohydrate to avoid the post exercise hypoglycemia and if they are planning to take the meal or bolus insulin one hour within one hour of exercise then they should decrease the bolus dose also this is a guide for decreasing the insulin level depending upon the duration of exercise and type of exercise if the patient is taking multiple doses of insulin or basal insulin then they need to decrease the dose of insulin according to the duration of exercise so every patient should be taught to decrease insulin levels to avoid the nocturnal hypoglycemia post exercise insulin secreta go medic patient should be in the patient with the type 2 diabetes they should decrease the doses of insulin secreta go while other medications are generally safe they doesn't cause hypoglycemia so there is no need to adjust these medications while if the patient is on beta blockers the clinician should know that the patient hypoglycemia awareness could have been masked because of the symptoms get masked by the beta blockers and they should be advised to check the blood glucose because the symptoms may not be there so you CDM can be used to in the patient who are at a high risk of hypoglycemia and it and the targets during the exercise should be kept between 126 to 180 milligram per dl and post exercise period the targets should be kept between the 80 to 180 milligram per deciliter so CGM also includes the shows the patients and that the exercises has done the beneficial effect on the their glucose level there so it will be a kind of motivation also for the patient to do exercise now we will discuss how in special situation like the if the patient has diabetic retinopathy if the patient is having unstable proliferative or severe diabetic retinopathy then they should avoid the exercises that includes strain, charring or valsarva maneuvers practically the patient should be advised to do exercises that that involves the bending at the waist or lifting overhead or doing the near maximal isometric contractions because there will be increased risk of retinal detachment or vitreous or retinal hemorrhages because of the increase in the blood pressure and force of auto regulation of retinal vessels so exercises can any exercise is contraindicated if the patient has done recent laser photocondylation and of the retina or recent surgery to the eye so the exercises that can be recommended to this kind of patient are simple walking swimming but with the caution that they should avoid the kick turns and cycling but they should not do mountain biking or high intensity of cycling while if running there is jarring moments so they should be avoided it should be avoided rowing can be recommended at low intensity basketball should not be recommended weight lifting horse riding these kind of exercises should not be advised while the patient with the nephropathy can be there is exercise it has been shown that there is no increase in the progression of nephropathy with the use of with exercise so exercise can be done the patient with the nephropathy but it should be kept in mind that the patient may have anemia they can be more they are more prone to get fatigued and they have low exercise reserve they are having diabetic retinopathy is the risk of cardiovascular disease so they should be screened for the cardiovascular disease before prescribing the exercise the VP should be controlled while prescribing the exercise and there are there is increased risk of dyselectrolyticness so with that should be monitored when the patient is doing moderate to vigorous intensity exercises so definitely there is improvement in the HbA1c and glucose levels there is improvement in the muscle mass if the patient is in resistance training and in overall well-being of the patient so it is good for the diabetic nephropathy patient but one should know that the post-exercise protein area is there which is transient so patient should know when the urine albumin ratio or 24-hour protein should not be measured for in the immediate post-exercise period so while describing the exercise in the patient with the loss of protective sensation there is the exercises that involve the injuries to the foot like that can cause foot injuries like treadmill for long walking jogging or weight-bearing exercises should not be recommended to these kind of patients that as they can increase the risk of soft tissue or joint injuries and they should be do they should be advised to do non weight-bearing exercise like swimming, bicycling, rowing, chair exercises, arm exercises these are all non weight-bearing exercises then they should recommend it these the patient with the active ulcers the there should be non weight-bearing to that ulcer part and even aquatic exercises should be avoided as they can cause infection on the open wound so and they should be advised proper foot care they should check the any signs of trauma or redness to the foot and they should be advised to proper wear the foot wears properly choose the they should be helpful to the foot wears and they should be advised the socks that are properly fit without elastic and they should these kind of socks should be should keep the feet dry completely cotton socks will keep the moisture so that is not recommended during the exercise period so they should avoid activities during that require excessive balancing capacity as the foot sensation will be look less so balancing may not be proper why if the patient with the hypertension it should be controlled before start recommending the exercise and proper hydration should be advised and they should avoid while saliva manures as it could lead to increase in the blood pressure so in the patient with the CAD or CVA then they should be taught about the symptoms then they should stop myocardial infarction or above all the stroke and they should immediately stop exercise if any of there is any of these symptoms and after a they can they should be advised to start exercise at a low intensity and gradually progress and both exercises can be done while the patient with the CHF should focus on low and moderate intensity exercises only as excessive heart rate increase should be avoided in this kind of patient patient with the peripheral artery diseases can do moderate intensity walking arm ergometer or any kind of exercises so before starting recommending the exercises they should be screened for the micro and micro vascular complications their baseline fitness level and what medication they are taking while ADA American Diabetic Association doesn't recommend pre-exercise evaluation proper formal exercise stress test in the patient who are asymptomatic and beginning the low to moderate intensity physical activity not exceeding the demand of risk walking or everyday living however American College of Sports Medicine advised the pre-exercise screening based on their symptoms and based on their disease based on their symptoms and based on their physical activity levels and desired exercise intensity if the patient is not participating in any regular exercise and it doesn't have any complications then they can start or continue exercise in at any intensity and they if they are they have known severe adrenal disease cardiovascular renal disease but they are asymptomatic whether or not they are doing any exercises previously they should be done a medical clearance and if there are sign and symptoms then also the medical clearance is recommended and if the patient is even if the patient is doing already physical activity they should be advised please continue exercise and seek first medical clearance according to the American College of Sports Medicine so how we can minimize the exercise related adverse event first of all hypoglycemia as we have discussed that each and every patient should be taught about the sign and symptoms of hypoglycemia so that so that they can detect the hypoglycemia early and they should carry the carbohydrate source during the exercise and they should have carbohydrate snack at least 30 minute prior to the exercise according to the blood glucose level as we have discussed so they can do short sprints or performing resistance training before or after the exercise after aerobic exercise provide the hypoglycemia and they should adjust the insulin dose to avoid the nocturnal hypoglycemia they should advise they should be advised to take bedtime snack and they can also use cgm continuous glucose monitor proper food care should be advised to each and every patient if the patient is proper hydration should be advised especially this the older patients and the patient with the autonomic neuropathy should be advised to not to do exercise in very hot and humid environment and regarding hydration this the general guide is to take around 240 cc of water every 50 water or any fluid with the electrolytes should every 20 minutes or the weight loss is the most accurate guide if the pre-exercise and post-exercise weight loss is 500 gram then they should take at least 460 450 cc of water and they should be advised to carry a cell phone or identification card by doing the exercise so the patient should be promoted to do exercise because it has definitive benefit in their metabolic health and they there can be adoption of behavior change strategies and technologically based they can technology can also be used to motivate them to do exercise this can be goal setting they can be given the appropriate goals they can be a proper feedback it can be taken from the patient they can with the support of online coach or they can use the proper reminders can be given to patients to promote the physical activity so the for the consist for making the exercise patients to do for for doing the consistent exercise the exercises should be that should be prescribed should be enjoyable that the patient should do be advised to do the to enjoy their workout they should schedule their workout they should track their progress so that it will be a motivation for them they should keep the goals so that they can achieve that goal but the goal should be set in that can be achieved so they can be advised to do mini workout if there are time constraints they can take the breaks they can do breakup exercises in small session throughout the day by where but if they are doing aerobic exercise they should be advised that at least 10 minute of aerobic exercise should be done at a one stretch and there can be exercises of different varieties can be included so new routine and new activities keep the patient motivated to do constant exercise consistent exercise and the exercises classes can be joined there can be social engagement to do exercise with the friend or join a gym or participate in the sport league to make the workout more enjoyable and accountable so to summarize physical activity and exercise should be recommended in all individuals with the diabetes mellitus as a part of their management of glycemic control and overall health the specific recommendation and precaution vary by the type of diabetes age of patient according to their activity baseline activity level presence of diabetes related complications so the recommendation should be tailored to meet the specific need of each individual all the adults should be encouraged to decrease the total amount of sedentary time and to break up the sitting time with the frequent bounds of exercise behavior seen strategies can be used to promote the adoption and maintenance of lifetime physical activity so for walking away from the diabetes there should be starting start patient should take one step to walk to do exercise so with this i would add my presentation and we will see if there are any questions we can take so one question is which type of exercise is good for bones as we have discussed the anaerobic exercises or the resistance training exercises has shown as shown as it has been shown in many studies they have the good effect on the bone mineral density improving the bone mineral density so resistance exercises are good for the bone health improving the bone mineral density particularly so the another question is if the patient has diabetes and osteoporosis which type of exercises are best so as it is linked to the similar previous question that if the bone strength thing that is resistance training are best but these kind of patient should avoid the exercises that poses the strain to the their weak bones for example they should avoid jumping if the osteoporosis affects the spine so that they may not develop any fracture while doing the exercise they should start slow they should take advice of the personal coach or healthcare trainer so do to start exercises so they should start gradually and empty they should progressively increase the workload what about the marathon runner with diabetes any special recommendations so as we have and we know the marathon is a long race long aerobic endurance activity long long aerobic exercise so there is increased use of hypoglycemic dehydration while doing the marathon so they should do they should take at least 15 to 30 gram of carbohydrate after each hour and proper hydration should be taken care of while doing marathon run oh i think we have taken most of the questions uh so thank you for joining and thanks again endocrine society for keeping this webinar thank you thank you have a great day everyone

diabetes

physical activity

exercise

metabolic benefits

FITVP model

glucose levels

anaerobic exercise

aerobic exercise

diabetes management

glycemic control