Dr. S.M.Sadikot,
Consultant in Endocrinology, Diabetes and Metabolic Disorders,
Jaslok Hospital and Research Centre, Mumbai.

When your doctor tells you to exercise, he is saying nothing new. More than 2000 years back, Charak, in his Charak Samhita advocated the use of exercise in treating diabetes. In fact, the use of exercise in the treatment of diabetes was prescribed as early as 600 BC by the Indian physician Sushruta, and was widely recommended by physicians of the 18th century. Elliott Joslin, often called the Father of modern diabetes, identified exercise along with dietary management and insulin administration as one of the three components of good therapy in the 1920's.

It could be argued that in the absence of any other forms of treatment, the older day physicians had no choice but to fall back on diet and exercise! Later, with the wide availability of oral hypoglycemic agents and insulin, the relative importance of exercise as a treatment for diabetes seemed to go into a decline from which it is just emerging.

With the longterm safety and efficacy of some of the oral agents being called into question and with reports that ill advised insulin therapy leading to high blood insulin levels can be a factor in leading to many disorders such as high blood pressure, lipid disorders and even atherosclerosis, attention is being again given to diet and exercise as the dominant treatment modalities, as far as possible.

If a diabetic can be managed with the use of diet and exercise alone, or if the addition of exercise can lead to a substantial decrease in the dose of the oral agent or the insulin, can there be any justification for not prescribing exercise to the diabetic!

But who likes to exercise, and too regularly. In the modern age where even the routine activity in daily life has been decreased due to the availability of modern gadgets and conveniences, exercise for many is the use of one's thumb to press the "Remote Control" button!

But..........

Do you still need more reasons to exercise?

If you are still not convinced, here’s a program of strenuous activities that do NOT require physical exercise.

But how does one go about exercising? Patients are often told that they must exercise! And many of us accept this. Today, if you went to a doctor with an infection, and were told "Take antibiotics!", would you accept this? Frankly, no doctor would give such advise. The doctor would need to prescribe the precise antibiotic that the you would need to take. You would also be told the strength of the tablets, the number of times you have to take the tablets daily, the number of days that the tablets need to be taken, the time of taking the tablets, the relationship with mealtimes and even the side effects that the patient may experience!

But when it comes to exercise, patients are told to exercise and they accept this advise. Such simple instructions may mean different things to different patients and from a therapeutic viewpoint are absolutely useless. Just as a prescription is written for any drug that the patient needs to take, it is essential that a detailed prescription of the exercise schedule be made for every patient. You should be evaluated for fitness to exercise and then there should be a discussion of the type of exercise, the intensity of the exercise, the timing and the duration of the exercise schedule.

It is also essential that you be advised about any special aspects, precautions and side effects associated with his exercise regime.

Before undertaking an exercise schedule, you will need to be evaluated for your fitness to exercise.

In my opinion, a good history and clinical examination along with a few routine investigations would tell the doctor if you are at special risk to undertake an exercise programme.

If you have a significant degree of ischemic heart disease, it may be better for you to follow a special cardiac program for exercise. In case you have been told that you have eye complications such as proliferative retinopthy, then you should avoid vigorous exercise atleast until you have been adequately managed by laser therapy. Similarly those with a significant degree of kidney involvement would also do well to avoid any sudden and vigorous activity. The feet of the patients, especially those with a severe degree of anaesthesia and peripheral vascular disease would require special attention. But the vast majority of people with diabetes can well follow an exercise schedule and should be made to do so!

It is needless to say that all diabetics who are put on an exercise program should be closely monitored atleast in the initial stages.

I would also like to point out that this initial evaluation does not entail any extra cost to you as this is a routine part of any good initial evaluation for every diabetic patient!

Should all patients have a cardiac stress test before they undertake an exercise schedule?

An exercise stress test may also be helpful to assess the cardiovascular system if an exercise program of moderate-to-high intensity is to be undertaken and there is high risk for underlying heart disease. It may be better to have a graded stress test if one of the following criteria is present:

• Age > 35 years
• Type 2 diabetes of > 10 years' duration
• Type 1 diabetes of > 15 years' duration
• Presence of any additional risk factor for coronary artery disease (smoking, high cholesterol, high blood pressure, obesity, stress)
• Presence of microvascular disease (retinopathy, nephropathy, microalbuminuria)
• Peripheral vascular disease
• Autonomic neuropathy

Here is a General Checklist which can help you judge your fitness to exercise.

Modified Physical Activity Readiness Questionnaire (PAR-Q) Regular exercise associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answer yes.

If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.

This Checklist is only for general guidance and it would be better for you to discuss your schedule with your doctor before starting on the exercise program.

Once you are found fit to undertake an exercise program, the next step is to choose the type of exercise you will undertake.

But before we even discuss the type of exercise, one very easy and simple step which you can take is to increase the activity level in your daily life. Here'show you increase you activity level

But if for some reason you are bound down to your chair for long periods, or you are kust plain lazy to get moving, here are some exercises for the “Couch Potato”.

Your exercise schedule will need to be followed over a prolonged period. Thus, the exercise chosen will need to be individualized for you. It will have to take into consideration your needs, work schedule, hobbies, interests, skills, ability and also, quite importantly, your financial abilities! In other words, the type of exercise that you choose should be one that you will be able to carry out easily, regularly and for a long period.

Isotonic exercises which involve the movement and use of large muscles are preferable for most people. Isometric or muscle tensing exercises like weight lifting, Bull worker and push ups are not suitable for most of the patients and should be reserved for the very young patients and athletes with a special interest in developing certain muscles. These isometric exercises are specially meant to develop muscles and stamina, but they also cause a significant rise in the blood pressure and this can be very dangerous for many diabetics, especially those that have any problem with their eyes and kidneys. These exercises are not easy to carry out on a regular basis. Isotonic exercises are definitely more safer, easier and more than sufficient to meet the needs of most diabetics.

It is important to take into consideration the work schedule of the patient when planning the type of exercise. A patient holding a nine to five job obviously cannot plan to play games or go swimming every afternoon. The patient must also have easy access to, or an opportunity to undertake the exercise that he chooses. Tennis, swimming, badminton, etc, are all excellent forms of isotonic exercises but one must consider whether the patient would be able to regularly carry out these forms of exercise! Does he have a regular and easy access to a swimming pool or a tennis court? This often means that he should belong to some club or hotel. These are not only quite difficult to come by, but are also quite expensive. Add to this, the cost of playing some games like tennis! Thus, one would not only have to consider if the patient would have an opportunity to carry out his exercise schedule regularly, but also if he would able to bear the financial burden of this exercise schedule! The skills and ability of the patient should also be considered. To give an extreme example, the patient cannot be allowed to choose hill climbing as his form of exercise, when he prefers to take a lift to the first floor!

It is also important that the exercise chosen should be of interest to you. You cannot become bored of the activity and stop exercising! One way out of this dilemma would be to choose different forms of exercise so that the type of exercise could be varied. But when someone is given too many choices, I find that he ends up doing none.

You may be wondering why I am laying so much stress on choosing the type of exercise. But from experience I know that quite a few patients have a tendency, in their initial enthusiasm, to choose some of the most exotic and fancy forms of exercise which they have no hope of carrying out for any period of time, thus defeating the very purpose of an exercise programme. Let us take an example from clinical experience. All of a sudden one finds that when we ask many of our patients, especially the younger ones, about the type of exercise that they would like to undertake, quite a few of them ones, about the type of exercise that they would like to undertake, quite a few of them choose to play tennis. This usually occurs in the month of July. A closer analysis would show that this is after the massive coverage given to the Wimbledon Championships on TV. I usually discourage all these sudden flights of fancy as these have a tendency to be quite shortlived, even if they ever take off in the first place.

Personally, I am in favour of walking as the type of exercise best suited for most patients. Walking needs no learning or special skill; after all, everyone knows ( or THINK they know) how to walk! Walking can be done easily, regularly, anywhere and anytime, needs no special equipment or place, is relatively the safest and costs nothing.

Do you really WALK correctly? find out here.

Once the exercises have been chosen, the next step is to learn at what intensity you will carry out the exercise. Remember, the aim of the exercise is to TRAIN the body and not to STRAIN it!

Therefore, the pace, initially, would need to be gentle and this could then be stepped up to optimal levels at a rate depending on the individual patient. It must be remembered that what one has not done for a lifetime, cannot be accomplished overnight! Inability to appreciate this simple but important point gives rise to a large number of patients who give up the exercise programme. The usual sequence is that patients in their initial enthusiasm exert at a strenuous pace and for a prolonged time. This causes in many cases, a severe bodyache and joint pains. In some cases, sprains and other more serious joint problems may also develop. The patient concludes that the exercise is causing too much hardship, has done him more harm than good. Whilst it may be excellent in principle, it is definitely not meant for him. That is the end of any exercise programme!

One cannot blame a patient for these excesses as these are quite human traits, and it is imperative that this initial exuberance be avoided. One only has to think back about one's childhood days when we went away for the holidays. On the first day, we would get our hands on a bicycle and pedal away furiously for hours on end. The next day, the body would be so stiff that it was difficult even to get up. All thought of doing any more cycling would be the furthermost from our minds. Therefore, the best maxim is slow and steady initially and this can then be gradually paced up.

How does one judge the intensity of the exercise? The best way is to judge it is by your heart rate when you are exercising.

One method is to use the concept of exercising depending on the percentage of one's Maximum Heart rate (MHR). This can be calculated for every patient from the standard formula: MHR = 220 - age of your age. In other words, if your age is 40 years, your MHR is 180. You can use the Heart Rate Monitor ( in the Calculators Section) to learn more about this.

No matter what your exercise goal, you need to work out at the "right intensity". Too hard and you run the risk of injury or you just quit because exercise is too painful. Exercise does not have to be painful to be effective. If you exercise too easy, chances are that you will never get where you want to be. Working out at the right intensity, called your "Personal Target Zone", is the key to your success. Your heart rate is the only true way to measure this.

Zone 1: THE HEALTHY HEART ZONE: 50%-60% of your individual Max HR. This exercise zone is at 50-60% of your maximum heart rate. Most people walking at a comfortable pace are in this zone. The body burns 85% fat, 10% carbohydrates and 5% protein when in this zone. This is the zone at which most of you will be walking in. Some of you will keep in this zone for almost all the time, others may use this as a stepping stone to a more vigorous exercise schedule in other Zones. This is also the zone in which the warming up and cooling off in your exercise schedule is done. This zone has been shown to help decrease body fat, blood pressure and cholesterol. It also decreases the risk of degenerative diseases and has a low risk of injury.

Zone 2: THE WEIGHT MANAGEMENT ZONE: 60% to 70% of your individual Max HR. It's easily reached by jogging slowly. While still a relatively low level of effort, this zone starts training your body to increase the rate of fat release from the cells to the muscles for fuel. Some people call this the "fat burning zone" because up to 85% of the total calories burned in this zone are fat calories which is equally as important. Fit and unfit people burn fat differently. The more fit you are, the more effectively you use fat to maintain a healthy weight. On the other hand, perhaps you've been exercising vigorously, but not losing the weight you expected to. Could be you've been working too hard and need to drop back to this zone and exercise longer. To burn more total calories you'll need to exercise for more time in this zone.

Zone 3 THE AEROBIC ZONE: 70%-80% or your individual Max HR. In this zone -- reached by running easily as an example -- you improve your functional capacity. In this zone of exercise intensity, the body uses both stored fat and carbohydrates for energy. At 70-80% of your maximum heart rate, 50% of your calories burned in this zone are fats, 1% are proteins and 50% are carbohydrates. This intensity zone is excellent for increasing the number and size of blood vessels, increasing vital capacity and respiratory rate and achieving increases in pulmonary ventilation, as well as increases in arterial venous oxygen. The aerobic phase of your workout should be of 50 minutes or less to prevent build-up of lactic acid. Always warm up with 5-10 minutes of easy pace and after the aerobic phase, cool down with 5-10 minutes at an easy pace.

Most of you will be exercising in Zone 1, although later some of you may opt for Zone 2. In my opinion, most patients should not aim for a higher intensity, although many texts do advise that once the patient gets attuned to the exercise, he may opt for a more rigorous schedule. I feel that is only the younger group of people undergoing athletic training who should aim for the very high rates.

As a matter of interest, once the person becomes very fit, his heart rate may not rise to a significant extent and may even remain at very low levels. Bjorn Borg, even when he was playing the Wimble don Championships, would have a steady heart rate of about 45. This shows how fit Borg was.

Many people get quite confused with all this talk about MHR and the need to take their own pulse. How then is he to judge the intensity of his exercise? One simple, though not ideal, way out is for you to judge whether you would be able to talk normally (i.e. as if carrying on a routine conversation whilst sitting comfortably) during the exercise. If you can easily do so, you are obviously not exceeding your targeted intensity and can gradually increase the pace of exercise upto a limit where you feel that you would be able to just carry on a normal conversation, without huffing, panting and getting unduly out of breath.

Stretching will add flexibility and can make your exercise more comfortable.

b Warm up for 5 minutes at an easy walking pace before stretching, never stretch cold muscles or you risk tearing them. Incorporate mobility exercises designed to take a muscle and joint through its range of motion. You will start at the top of your body and work your way down.

Find an upright pole or fence or wall that will support you for leaning into on some stretches.

Head Circles: Make 1/4 circles with your head. Start with your ear near your shoulder on one site, rotate your head around to the front, ending with your ear near the shoulder on the other side. Roll your head back to the other side. Repeat 5-10 times.

Arm Circles: With one arm at a time, make backwards arm circle with your palm facing out, thumb pointed up. Repeat 10-15 with each arm. Then make forward arm circles with palm facing in, thumb pointed down, repeat 10-15 times.

Hip Stretch: Stand up, take a half-step back with the right foot. Bend your left knee and shift your weight back to your right hip. While keeping the right leg straight, bend forward more and reach further down your right leg. Hold for 15-30 seconds. Switch sides.

Quadiceps Stretch: Stand erect, holding onto a wall for support. Bend your knee behind you so that you can grasp your foot, holding your heel against your butt. Stand up straight and push your knee gently back as far as you can, the hand just keeps the heel in place. (For some, it is more comfortable to use the hand from the opposite side). Hold for 15-30 seconds, then switch.

Calf Stretch: Calf stretch Stand an arm's-length from the wall/post. Lean into wall/post, bracing yourself with your arms. Place one leg forward with knee bent - this leg will have no weight put on it. Keep other leg back with knee straight and heel down. Keeping back straight, move hips toward wall until you feel a stretch. Hold 30 seconds. Relax. Repeat with other leg.

Achilles Stretch: From the calf stretch position, bend the back knee so that the angle is changed to stretch the Achilles tendon. Keep your heel down, hold 15-30 seconds. Then switch legs.

Leg Extensions: Facing the pole, hold on with both hands. Bending at the knee, bring one leg forward, then extend and swing that leg back and behind. Repeat 10-15 times, then switch legs. Be cautious of hyperextending your lower back.

Cross Over Leg Swings: Holding onto the pole or fence rail with both hands, face forward. Swing one leg in front of your body gradually swinging higher. Swing about 10-15 times with each leg.

After stretching and mobility exercises, now you are ready to walk the main portion of your walk at your desired speed.

Every time you exercise, you should have a five minute warming up period when the pace of the exercise is quite mild and it is only after this gradual warming up period that you should raise his intensity levels to the targeted heart rate. At the end of each exercise period, there should always be a five minute cooling off period, when the intensity of the exercise is gradually decreased and the heart rate brought back to the basal levels. In other words, the exercise should never be started or stopped abruptly.

Why is warming up so important? The main purpose of warming up is to increase your heart rate slightly. This has two benefits: 1) it raises your core body temperature; and 2) it increases the blood (oxygen) flow to your muscles to prepare your body for more vigorous physical activity. Your muscles and tendons (which attach your muscles to your bones) will be more flexible for stretching after mild movement has raised your internal body temperature. This flexibility helps you increase the range of motion of your joints and may help you avoid injuries such as muscle tears and pulls.

What muscles should you warm up? Focus on warming up large muscle groups (i.e. quadriceps, calves, chest, etc...). People who are using walking as their form of exercise should start off with a slow stroll and gradually increase the pace. Runners/joggers could begin their run with a fast walk for 3 to 5 minutes followed by a stretch prior to the actual run itself. In an aerobic class, participants can march in place, do knee lifts etc. for the legs. To warm up the chest and shoulder area, participants do shoulder rolls, arm circles etc.

It takes your body approximately 3 minutes to realize it needs to pump more blood to your muscles. Warm ups should last approximately 5 - 10 minutes.

Why Cool Down? After you've reached and maintained your training heart rate level in the aerobic portion of your class, it is important to recover gently. The cool down serves two purposes: 1) it reduces your pulse; and 2) it returns the blood to your heart in sufficient quantities to rid the muscles of lactic acid (a chemical result of muscular fatigue). If you stop suddenly, the blood will pool in your legs instead of returning to your heart. Dizziness, nausea and a "worn out" feeling are common symptoms of an improper cool down.

It takes your body approximately 3 minutes to realize it does not need to pump all the additional blood to your muscles. A safe cool down period is at least 3 minutes, preferably 4-5 minutes.

All cool downs should be followed by stretching of the muscles to avoid soreness and tightness.

Another important precaution that must always observe is that if, for any reason, you have to interrupt the schedule of regular exercises, you cannot restart it at the same level of intensity that he left off at. You should begin the exercise schedule anew as if you were starting to exercise for the first time' and then gradually come up again to the targeted intensity. If you restart the exercise at the same high level of intensity, it would be as if you were undertaking a sudden and very rigorous exercise and this can cause quite a few problems.

If you have chosen walking as your exercise, you should judge a certain known distance from his house (or wherever you will regularly walk) and time yourself to see how long it takes to walk the distance at his normal speed. Gradually increase the speed of walking such that you can cover the distance in a shorter time and this speed is increased until you are walking at your at an intensity within your chosen Personal Zone. The distance is then increased such that you are able to exercise at the required intensity and for the required period each time. This is an approach that most can understand quite easily and follow regularly. Even when the form of exercise is walking, there must be the five minute warming up and the five minute cooling of intervals.

Sample Plans for Walking, Walk-Jogging and Jogging are given here. These can be followed to reach the intensity which has been deemed proper for you.

Ideally, you should exercise every day, but if this is not possible, it has been shown that for exercise to have a beneficial effect, it should be done for at least five days in a week.

Each exercise session should be of around 40-45 minutes which should include the time for warming up and cooling off. You may break up the sessions into two, but each must have a warming up and cooling off period. At the same time, try and avoid breaking up the daily exercise schedule into many small parts. Often, most of these never get done!

Is there a time of day when it would be preferable to exercise so that one could get the maximum long term benefit? The short and simple answer is NO, so you can exercise at a time convenient to you.

What should I wear?

There seems to be some craze for wearing track suits during the exercise. These are usually made from impermeable materials and are totally unsuited for our climate. They prevent heat loss from the body and also stop the sweat from evaporating. This could lead to a dangerous increase in the body temperature and in some severe cases, may even cause a heat shock. There is absolutely no need to spend any money on special clothes for the exercises. You should choose loose comfortable clothes (which allow the free circulation of air). After the exercise, especially if the weather is cold, it would be preferable to cover oneself more thoroughly in order to avoid catching a chill.

What you should do is buy yourself a good pair of shoes for your exercise. Here are some tips on how to buy shoes which are the most suitable for you.

Does my blood glucose levels have any thing to with my starting to exercise?

Your pre-exercise blood glucose level will affect whether or not you should exercise:

As we have said before, the aim of your exercise is to train your body and not strain it! One of the most important aspects of your exercise program is to start slowly and build up the intensity level gradually until you have reached your targeted level of intensity.

One of the major areas of danger is sudden, vigorous exercise undertaken when your body has not been trained for it, or if the exercise you perform is way beyond your targeted limits. You should listen to your body for early warning signs that you may be overdoing your exercise or if anything is going wrong. Exercising too much can cause injuries to joints, feet, ankles and legs. So don't make the mistake of exercising beyond early warning pains in these areas or more serious injuries may result. Fortunately, minor muscle and joint injuries can be readily treated by rest and aspirin.

You should always be aware of the possible signs of oncoming heart problems, such as:

• Pain or pressure in the left or mid-chest area, left neck, shoulder or arm during or just after exercising. (Vigorous exercise may cause a side stitch while exercising - a pain below your bottom ribs - which is not the result of a heart problem.)
• Sudden lightheartedness, cold sweat, pallor or fainting. Ignoring these signals and continuing to exercise may lead to serious heart problems.
• Should any of these signs occur, stop exercising and call your doctor.

Please ask your doctor about the exercise if you have been told that you have an eye complication.

We have already discussed that any patient who has a severe degree of proliferative retinopathy should get the eyes treated with laser therapy before embarking on any exercise. Any diabetic who has retinal problems should avoid any sudden and vigorous spurt of exercise. The reason is that in an unfit and uncontrolled diabetic, this could lead to a sharp rise in blood pressure and cause a bleed in the eye. This is also the reason why patients should avoid isometric forms of exercise as these tend to raise the blood pressure. This does not mean that a diabetic with even a small degree of retinal problem should never exercise.

Quite a few of the patients also suffer from involvement of the autonomic nerves. These are nerves that have a myriad of functions, one of which is to regulate the blood flow to the different regions of the body. During exercise, more blood flows to the peripheral areas, like the skin and the exercising muscles. This is the blood that is diverted from the internal organs. The autonomic nerves finely regulate this change in the blood flow such that the periphery gets the additional blood, and at the same time, the internal organs are not starved of their blood requirements. In patients with a severe degree of diabetic autonomic neuropathy, sudden and vigorous exercises may divert so much blood to the periphery, that the internal organs may not get sufficient blood. Diabetics with nephropathy may, in exceptional cases, have so much of a decreased blood flow to the kidneys that these may "shut down". In some others, blood flow to the brain may decrease such that the patient may get quite faint.

Once again, I would like to make it clear that this usually occurs in patients who undertake very sudden and vigorous exercises without being trained to with- stand such stress.

Here again, the key words are slow and steady!

When you have diabetes you are at greater risk for foot injury when you exercise. Nerve damage may decrease your ability to feel an injury to your feet. Impaired circulation can mean slow or poor healing when injuries do occur. Prevention of injury to your feet is very important. When you talk to your doctor about starting an exercise program, you will be advised about whether your legs and feet can safely tolerate the type of exercise your are planning.

Check your feet before and after exercise. Look for breaks in the skin, redness, blisters, or unusual swelling. If any of these problems occur, contact your doctor immediately. Wear shoes that fit properly and that are appropriate for the type of exercise you will be doing. Wear cotton socks, preferably white, and change them during exercise if they become damp.

The use of proper shoes is essential.

The climate in India can get very hot and in some parts this is often accompanied by high humidity. If precautions are not taken during hot, humid days, heat exhaustion or heat stroke can occur - although they are fairly rare.

Heat stroke is the more serious of the two. Their symptoms are similar:

The last two symptoms of heat stroke are important to know. If the body temperature becomes dangerously high, it can be a serious problem.

Both heat exhaustion and heat stroke can be avoided if you drink enough liquids to replace those lost during exercise.

• Watch out for signs of heat stroke - feeling dizzy, weak, light- headed, and/or excessively tired; sweating stops; or body temperature becomes dangerously high.
• Wear a minimum of light, loose-fitting clothing.
• Avoid rubberized or plastic suits, sweatshirts, and sweat pants. Such clothing will not actually help you lose weight any faster by making you sweat more. The weight you lose in fluids by sweating will be quickly replaced as soon as you begin drinking fluids again. This type of clothing can also cause dangerously high temperatures, possibly resulting in heat stroke.

The important point is that you should not let yourself get dehydrated and should drink lots of water before, during and after exercise.

Some parts of India can also get very cold.

• Wear one layer less of clothing than you would wear if you were outside but not exercising. It's also better to wear several layers of clothing rather than one heavy layer. You can always remove a layer if you get too warm.
• Use old mittens, gloves, or cotton socks to protect your hands.
• Wear a hat, since up to 40 percent of your body's heat is lost through your neck and head.

Change may be necessary for some of the patients although this may not be something that you would need to do every time you exercise. The reason for this is that, if you have a regular exercise schedule, your diet and medications will have taken this into consideration and would rarely require adjustments. At the same time, you should be aware about the modifications that they may have to make during exercise schedule.

It is possible that you may have to carry out a vigorous activity unexpectedly, or on occasion, you may feel like exercising for a more prolonged period, or at a time which is not your usual time for exercise and therefore, this may not have been taken into account whilst planning the diet and treatment.

Change may be necessary for some of the patients although this may not be something that you would need to do every time you exercise. The reason for this is that, if you have a regular exercise schedule, your diet and medications will have taken this into consideration and would rarely require adjustments. At the same time, you should be aware about the modifications that they may have to make during exercise schedule.

It is possible that you may have to carry out a vigorous activity unexpectedly, or on occasion, you may feel like exercising for a more prolonged period, or at a time which is not your usual time for exercise and therefore, this may not have been taken into account whilst planning the diet and treatment.

It is better to understand the changes which take place when you exercise so that you better comprehend the adjustments which may have to be made by you, if necessary.

This is done through the liver making new glucose and pouring it into the circulation. Insulin inhibits this, whilst glucagon and other antagonist hormones increase the amount of glucose formed by the liver. It is apparent that there is indeed a fine tuning of the balance between the insulin and its antagonist hormones such that the blood glucose levels would be maintained within acceptable limits. Although the changes during exercise are definitely much more complicated than this, I have kept the discussion to these simple terms so that the modifications required in the treatment can be self apparent.

Let us first consider the patient who has just taken his insulin injection. Obviously, his blood insulin levels would be high and since this is insulin which has been injected, there is no way that the body mechanism can decrease the levels of the insulin when exercise commences. These relatively high insulin levels would exert their effect and prevent the liver from forming new glucose. This would be inspite of the increase in the amount of the antagonist hormones. Therefore, as the patient exercises, and the muscles use up the glucose, the body would not be able to increase blood glucose levels and there would be tendency for the patient to go into hypoglycemia. Whilst this decrease in the levels of the blood glucose is one of the benefits of exercise, in a finely controlled patient, undue exercise could make him severely hypoglycemic.

Thus, it becomes quite apparent that the problem for patients taking insulin would be:

a) to try and decrease the blood levels of insulin such that this would not inhibit the ability of the liver to form new glucose and thus maintain the blood glucose levels to within acceptable limits.

b) increase the intake of carbohydrates such that this would make up the decrease in the capacity of the liver to form new glucose;

How can these problems be managed? This can be quite easily managed by:

a) decreasing the dose of insulin that the patient takes prior to the exercise;

b) take additional carbohydrates before, during or after the exercise;

c) you may have to do all three if the exercise is sufficiently vigorous and of a long enough duration.

Another way to keep your blood glucose under control while you are exercising is to adjust your medication. But before major adjustments to your medication, check with your doctor to ensure you are making the correct decision.

The table below provides some general guidelines for insulin adjustment during exercise:

* Low = not in target heart rate zone **If Regular insulin - 2 - 4 hours after injecting

Moderate = low end of heart rate zone If NPH/Lente - 6 - 12 hours after injecting

High = high end of heart rate zone

You should take special precautions. Otherwise, the combination of insulin action and exercise may cause hypoglycemia. You should eat extra food before beginning the activity if you exercise when your insulin is peaking:

If your treatment has been prescribed taking your diet and exercise in consideration, the chances for becoming hypoglycemic is not common, but you should be prepared and be able to recognize the signs and symptoms associated with a low blood glucose so that you can take preventive measures and not have a severe hypoglycemic reaction.

Strategies for Adhering to Your Exercise Program

People with diabetes are often amazed at how well exercise can help them control their blood glucose. Even so, adhering to your exercise regimen can be difficult because it takes planning, time and discipline. Below are some strategies that you can use to help you maintain your exercise plans and continue to gain the benefits from your efforts:

• Choose exercise that you enjoy. It is easiest to avoid something that you don't like.
• Choose a variety of activities that you enjoy to prevent boredom.
• Set realistic goals for your exercise program. If you set goals that are unrealistic for you, then you may become discouraged and quit.
• Keep your program convenient to your lifestyle. Exercise is more rewarding if it doesn't interrupt the normal flow of your life.
• If you are self-conscious about exercising, find a group of people at a similar fitness level for companionship.
• Give yourself rewards for achieving your exercise goals.
• Exercise on a routine basis so that it becomes a normal part of your life.

Aside from the physical benefits of exercise, it can give you a psychological boost, increasing your sense of well-being, your self-image, and help you manage your stress better.