Increased daily routine physical activity and regular exercise is recommended as an important component of all lifestyle management regimens to prevent and manage the metabolic syndrome as well as all diabetes management regimens.

Increasing physical activity assists in weight reduction, reduces insulin resistance, has beneficial effects on metabolic risk factors; and importantly, it reduces overall ASCVD risk beyond that provided by weight reduction alone.

It is however being increasingly recognized, that exercise programs carried out without adequate precautions, do carry some risks as well. The potential adverse effects can be on the cardiovascular as well as on the musculoskeletal systems. Incautiously carried out severe exercise, may predispose patients undergoing drug therapy for diabetes to unexpected hypoglycemia, and also, exacerbate existing diabetic complications leading to retinal bleeds and significant increase in renal dysfunction.

These risks can be minimised with pre-exercise screening, individualised exercise programme prescription, careful monitoring and patient education.

All patients should undergo a complete history and examination to identify cardiac, macro/microvascular and neurologic complications. The extent of investigations would dependent on the risk level of the patient and would need to be individualised.

Exercise should not be prescribed to patients with very high blood glucose, and those in ketosis, unless treated adequately.

Patients with significantly retinopathy and renal dysfunction may also need to undergo specific treatment before embarking on an exercise program.

Patients with foot infections should avoid exercise until adequately treated.

Patients with cardiovascular abnormalities and/or uncontrolled hypertension should not undertake exercise unless this is in close consultation with cardiologist.

The exercise should be aerobic and isotonic.

Although the patient may be allowed to choose his own form of exercise, walking would appear to be the most appropriate, and safe, exercise for most patients.

Isometric exercises, such as weight lifting, etc., are not recommended for most patients although they warrant consideration when total skeletal muscle mass needs to be increased.

Patients should be encouraged to increase "every day" activities such as taking the stairs instead of the elevator.

Regular moderate-intensity physical activity; at least 30 min of continuous or intermittent (and preferably 60 min) 5 d/wk, but preferably daily, with a five minute warm up and a five minute cooling off period. The duration and frequency may be adjusted to individual needs.

The intensity of the exercise needs to be individualised.

For most patients, exercise should be initiated slowly, and the intensity should be increased gradually. The exercise can be done all at one time or intermittently over the day. Initial activities may be walking or swimming at a slow pace. The patient can start by walking 30 minutes for 3 days a week and can build to 60 minutes of more intense walking at least 5 days a week, preferably daily. Before more strenuous exercise, a warm-up period of 5 minutes of stretching and other gentle activity is advised, as is a final cool-down period of progressively decreasing vigor.

The intensity of the exercise should be increased gradually.

Intensity is usually measured in terms of the percentage of the patients maximum heart rate (MHR). Initial exercise should be at a reduced intensity which should be at a reduced intensity which should then be increased to reach about 60-70% of the MHR. (MHR = 220 - age of the patient).

Limiting the intensity of the exercise such that the systolic blood pressure does not exceed 180 mm Hg would seem prudent.

Any patient undergoing an exercise program, who complains of any signs or symptoms which would have contraindicated such a program initially, should discontinue the program, and have a detailed re-evaluation before restarting the exercise regimen.

When the patient does start the exercise program again, the intensity should be such as if the patient were beginning the exercise program anew. The exercise program should never be restarted at the intensity at which it was discontinued.

An excellent parameter to judge, is that the patient should be able to carry out a normal conversation whilst exercising, without getting unduly breathless.