Advice for patient education about exercise

When counseling patients with type 2 diabetes about their exercise habits, consider this advice:

• Individualize exercise regimen to the patient.
• Caution patients regarding hypoglycemia during and after exercise.
• For those patients who can exercise, consider beginning with 15 minutes of low-impact aerobic exercise 3 times per week with the aim of eventually achieving accumulative exercise of 150 minutes per week.

This content is from ACP Smart Medicine, the College's new Web-based clinical decision support tool developed specifically for internal medicine physicians. Information about ACP Smart Medicine is online.

Commentary from ACP DiabetesMonthly's physician editor:

Recently, a patient with type 2 diabetes asked me, “Do I need to continue to exercise?” He had read about recent trials that failed to show the benefit of exercise in preventing complications in established diabetics and was hoping I would back off on my routine questions about his exercise habits. While I acknowledged the accuracy of his report, I responded with an unequivocal “Absolutely!” These trials have been disappointing in terms of decreasing cardiovascular end points in mature diabetics, but we need to ensure our patients do not get the wrong impression from media reports. In the general population, the evidence supporting the benefits of routine exercise is overwhelming both in terms of mortality benefit and quality of life.

I have been making a point to routinely review the proven benefits of exercise with my prediabetic and diabetic patients, including:

• the incontrovertible evidence that exercise decreases diabetes risk,
• the clear benefits of exercise in improving insulin sensitivity and easing diabetes management, and
• the proven ability of exercise to decrease blood glucose levels.

On this last point, I directly discuss the advice given to patients with type 1 diabetes a generation ago that exercise was contraindicated in hyperglycemia and explain that this just doesn't apply to type 2 disease. In fact, when a type 2 diabetic has an elevated blood glucose level, I strongly recommend exercise, such as a walk, to help bring blood glucose closer to target. I also remind type 2 diabetics to carry some form of sugar (hard candy, glucose tablets, raisins) in the unlikely event that hypoglycemia develops.

Other common questions I encounter during this conversation include “Does it matter what type of exercise I do?” “Does it have to be aerobic/cardiovascular?” “Does weightlifting count?” “Do I have to go to the gym?” and, finally “Does the exercise have to be all at one time or do short bursts count?” My interpretation of the literature is that any activity is better than none. Yes, mowing the lawn, walking the dog and even chasing grandkids in the park count. I often find myself trying to come up with creative ways to allow and encourage any activity in my patients, especially diabetics.

To sum up, while the recent trials have not been able to demonstrate conclusively that relatively short-term exercise (a few years) helps, embracing physical activity is clearly in our patients' best interests. So keep them moving!