Lifestyle management(2):Physical Activity
What constitutes physical activity?
Special considerations in diabetes
What constitutes physical activity?
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Physical activity refers to all forms of bodily movements which use energy and includes tasks such as housework, gardening and cleaning the car, as well as activities such as walking, cycling, running, aerobics and so on
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Adults should try to build up gradually to accumulate 30 minutes of moderate intensity physical activity on five or more days of the week
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Sustained activity is probably more effective health wise, so ideally patients/clients should aim for activity to last 15-30 minutes at a time. However, every bit of activity is important, and it is important to build on this principle when encouraging individuals to be more active
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Key principles of this message based on the FITT principle
Frequency |
Everyday (minimum of 5 days a week), incorporate into daily routine |
Intensity |
Moderate e.g. brisk walking. Moderate activity is one that should make the individual breathe harder than normal and become warmer. Start where the individual is at, activity should be built up gradually |
Time |
Accumulate 30 minutes (can be done in bouts of 10-15 minutes to achieve 30 minutes in one day) |
Type |
Anything from formal/structured activity e.g. organised sport/fitness classes, to informal lifestyle activities e.g. walking, cycling, gardening |
Mild Activity |
Minimal effort e.g. yoga, easy walking, light housework/gardening |
Moderate Activity |
Breathing harder than normal and feeling warmer e.g. brisk walking, tennis, badminton, swimming, line dancing, light aerobics, heavy gardening-digging, mowing; heavy housework-washing floors, windows |
Vigorous Activity |
Heart beats rapidly, breathing hard e.g. running, jogging, squash, cycling, aerobics, football |
Benefits
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Physical activity plays an important role in the prevention and management of Type 2 Diabetes. It is more effective than Metformin at reducing progression to type 2 diabetes in people with impaired glucose tolerance. It helps in type 1 type 2 management by:
- Decreasing insulin resistance/increasing insulin sensitivity
- Improving blood glucose levels (glucose tolerance)
- Promoting weight loss/reducing central obesity- which contribute to lowering insulin resistance
- Producing desirable changes in muscle tissue -
Regular physical activity has been shown to reduce the risk of cardiovascular disease, particularly CHD and stroke by improving the lipid profile and blood pressurel
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Additional benefits of regular physical activity include reduces anxiety / stress and improves mood, which can contribute to better diabetes self management.
Raising the issue
Ask patients about their activity levels
• Record whether patients are physically active in line with current guidelines (refer to "Read codes" for appropriate recording of this information)
• What types of exercise or physical activities have you done in the past?
• What made you stop these activities?
• How ready are you to start taking more physical activity on a regular basis?
• Do you think you would benefit from being more active?
• Think about the last seven days. How many times on average did you accumulate 30 minutes of the following kinds of activity throughout the day?
Assess motivation
After taking a patient history regarding their activity levels, you can establish a patient's motivation, and stage of change in relation to physical activity. Choose one statement that you feel most accurately describes them, from the following list:
A They are not currently physically active, and do not intend to become more active in the next six months/ too busy at present (pre-contemplation)
B They are not currently very physically active, but are thinking about increasing the amount of activity they take (contemplation)
C The amount of activity they take varies, sometimes being active, other times not (preparation)
D They are currently physically active on most days, but have only begun to be so within the last six months (action/maintenance)
E They are currently physically active on most days, and have been so for longer than six months (maintenance)
F A year ago they were physically active, but in the last few months have been less active (relapse )
Advise
• For those patients that meet the current physical activity guidelines encourage and review.
• All diabetic patients and those with CHD or risk factors, should be advised on the benefits of becoming more physically active.
• For those who are interested in becoming more physically active, (at contemplation and preparation stages on the cycle of change model) advice should be tailored to suit each individual patient according to their ability, age, mobility and taking into consideration their clinical conditions and / or risk factors
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For patients who would like to become more physically active, brief advice covering the 30 minutes of moderate intensity activity on 5 or more days of the week can be given in 5-10 minutes. Key issues to be covered with the patient will include misconceptions about activity and required levels. Plan for change by discussing any perceived barriers to success
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Consider issues such as
- time
- cost - equipment, membership fees
- access to facilities, transport
- social surroundings, family, friends etc
- lifestyle / job
- likes / dislikes
- age
- health
- glycaemic control
- risk of hypoglycaemia (see "Safety and Education" section below)
- mobility -
Encourage the patient to develop an action plan and to set realistic goals. For any activity to be sustained by the patient, it needs to be one that is suitable for them and that they will enjoy. Fun, sociable and regular activities may increase commitment to activity. The action plan should include:
- Start dates
- Types of activity
- Glucose monitoring
- Frequency
- Venue
- Aim for a week by week build up of activity levels
Regular follow up and support is an important factor in maintaining successful change. When patients attend for follow up or review appointments, check how they are progressing with their action plans. Provide encouragement and support. Ask about whether they are experiencing any problems, particularly regarding glycaemic control etc. Different people may notice improvements in their fitness in different ways such as less short of breath after climbing stairs. Physical changes may include weight loss; physiological changes may include improvements in blood glucose and blood pressure readings; psychologically, patients may have a sense of well being and feel better able to cope with stress; socially, patients may have joined activities and have made new friends. Highlighting all these physical, physiological, psychological and social benefits will also increase the confidence of the patient and be a motivating factor to continue activity.
Special considerations in diabetes
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Remind the patient that they should tell someone where they're going and for how long
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Remember to assess the patient's starting point. They should aim to build up to recommended levels for activity gradually over a period of a few weeks
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Begin activity session slowly and build up gradually (warm up). At the end, slow down gradually (cool down)
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Important to maintain fluid levels whilst undertaking activity to prevent dehydration. Dehydration can affect blood glucose levels and heart function
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Provide education covering normal responses to activity, such as breathing quicker, muscle tightness in order to prevent people assuming that they are doing themselves harm e.g. overweight individuals may experience breathlessness even with walking slowly. Encourage people to build up slowly within a comfortable range
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Education on foot care- proper and well fitting foot wear, feet should be monitored closely for blisters and other potential damage to the feet before and after physical activity
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Patients treated with insulin or sulphonylureas/secretagogues may be at risk of physical activity induced hypoglycaemia, so it is important for patients to be aware of how to manage these conditions during activity. Those taking Biguanides, Glitazones or other oral agents (and are not treated with insulin or sulphonylurea medication) are unlikely to have a hypo whilst engaging in physical activity. However they may need food soon after they have been active. It is wise to give the same precautions about physical activity hypo's (see next sections "Management of diabetes during physical activity - Hypoglycaemia and Hyperglycaemia").
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Encourage patients to maintain a physical activity diary, recording type of activity, duration, pre and post blood glucose readings etc
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Have regular reviews with patient to review physical activity diary and monitor effects of physical activity on clinical symptoms, glycaemic control etc.
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People who are on insulin therapy or sulphonylurea/secretagogue medication need to be aware of hypoglycaemia when participating in physical activity
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Blood glucose should be tested before and 2 hours after physical activity. Also during activity if longer than an hours duration
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Sensible to avoid activity at times of peak insulin activity (1-2 hours after injection)
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Injecting into a body part being used predominantly in the activity (e.g. leg if going cycling) will speed up insulin action. Injection sites should be away from areas used in the activity
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Reducing insulin - doses may need to be adjusted. It may be a matter of trial and error to determine what suits an individual for different activities, intensity and duration. This should be discussed with the person's diabetes team
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Increasing carbohydrate. If activity is planned after a meal, extra starchy carbohydrate e.g. pasta, potato, bread should be eaten at the meal. A snack (e.g. cereal bar, small chocolate bar or fruit) should be eaten before activity, if is one to two hours since the person's last meal. If participating in vigorous physical activity they may need a glucose top up (e.g. lucozade drink (60-90 kcals) every 30 minutes). If activities last a long time (e.g. a long walk or cycle ride), fast acting carbohydrates should be taken and snacks eaten regularly
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Fast acting snacks or drinks should be to hand when participating in activity
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Meal adjustments and bedtime snacks are advisable after vigorous activity. Delayed hypos can occur up to 36 hours after the activity as muscles and liver use carbohydrates to restore pre-exercise levels of stored glucose (glycogen). This can be avoided by increasing carbohydrate foods and by reducing insulin dose.
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Large quantities of alcohol should be avoided after physical activity as it lowers blood glucose levels
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Hyperglycaemia can occur when a person with diabetes engages in physical activity if there is a lack of insulin or blood glucose control is poor. For people with type I diabetes, ketoacidosis can also occur (the absence of insulin means that glucose cannot enter the cells. If muscles are contracting during activity, the body will try to find another source of fuel and turns to burning up body fat - thus causing ketones to occur in the urine 5 ).
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High blood glucose levels may also occur during or after activity when:
- Insulin levels before activity have been reduced more than necessary for the energy requirements of the activity
- High glucose snacks have been eaten during or after activity to prevent hypoglycaemia
- The person is nervous or excited e.g. in a competition event - this may cause blood glucose to be elevated -
For a person with type 1 diabetes, if there are ketones present in the urine, there may not be enough insulin to mobilise glucose for muscular work. Physical activity should be delayed until their urine is free from ketones, and blood sugars are in a safe range. The person may need to take extra insulin to improve uptake of glucose by the cells
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Everyone is different! Different activities will have differing effects on individuals and their blood glucose levels. It may mean a certain amount of experimenting and adjusting insulin doses and carbohydrate intake to keep blood glucose levels in a safe range. By doing regular blood glucose tests, individuals will be able to assess whether they have eaten enough or altered their insulin regime correctly. For the individual it may seem a chore in trying to monitor and manage their diabetes given the changes that participating in a physical activity regime may bring. It is important that they are supported and encouraged to persevere in being active, given the immense benefits that physical activity can have with diabetes management and their overall health and well being
Complication |
Recommendations |
Contra-indicated activities or in circumstances as stated |
Precautions |
Cardiovascular disease risk or presence: |
Low impact aerobic activities, such as walking, cycling, swimming. Supervised sessions to increase confidence in safe levels of exercise |
Recent MI less than 6 weeks Hypertensive activities such as heavy weight lifting, high intensity Arrhythmias or palpitations - check with cardiology team before advising patient |
Increase heart rate gradually If chest pain experienced during activity, advise to stop, rest and use GTN spray or tablets. If pain relieved wait 5 minutes before resuming activity. If pain continues repeat cycle of medication and rest (up to 2 times more) if pain persists seek medical help immediately |
Hypertension
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Low impact aerobic activities, such as walking, cycling, swimming. |
SBP should not exceed 170 Avoid isometric or heavy weights exercises |
Avoid activities where having to hold breath e.g. lifting (increases strain on heart) If taking beta blockers - don't use heart rate as an indication how hard you are working (heart rate will be reduced due to effect of medication) |
Proliferative Retinopathy
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Low impact or seated aerobic activities, such as walking, cycling, swimming, rowing machines |
Do not exercise after treatment for photocoagulation or surgery. Avoid all hypertensive activities plus head stands, bending at the hips and contact sports |
Gradual increases in intensity Avoid SBP >170 |
Peripheral Neuropathy
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Low impact or seated aerobic activities, such as cycling, swimming, rowing machines |
Avoid step-based activities, high impact and high intensity |
Full pre-exercise screening for sensitivity Cushioned shoes |
Nephropathy |
Weight bearing, low intensity aerobic activities |
Maintain BP control, follow hypertensive restrictions given for retinopathy |
Particular emphasis on hydration |
Autonomic neuropathy |
Low impact and low intensity aerobic activities, such as stationary cycling or water-based activities |
High intensity Rapid changes in body position |
Imperative to maintain BP to avoid postural hypotension. Note that temperature control may be difficult as there is sometimes excessive sweating of the upper body (hyperhydrosis) and/or absence of lower body sweating (anhydrosis) |
Peripheral Vascular Disease i.e. Intermittent claudication |
Low-impact aerobic activity such as walking, cycling, or swimming |
No anaerobic activity as increasing muscle bulk tends to worsen symptoms. |
Rest when painful |
Charcot's syndrome |
Low-impact aerobic activity such as walking, cycling, or swimming |
Do not exercise while CS is active: put in plaster and ensure total non weight bearing exercise for 2-3 months |
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Impaired Mobility
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Activities that promote strength, range of movement and maintain function |
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Obesity/Insulin resistance
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Low impact aerobic activities, such as walking, cycling, swimming. |
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The very overweight may be breathless on quite moderate effort: gradual increases, reassurances and support will give this group, who have a lot to gain, confidence to continue |
Exercise referral scheme
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The GP Referral Exercise Scheme or 'Vitality' Scheme is a project concerned with developing a Community Heart Disease programme to help sections of the adult population who have been identified as at risk from coronary heart disease.
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This project will introduce a personalised activity programme for each participant and through the referral induction and one to one time with the instructors, highlight and promote a healthier lifestyle. In essence the project is seeking to reduce the number of adults that experience a coronary event.
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Initially the scheme has been running in the Llanelli area, and presently expanding the service to leisure sites in Ammanford, Carmarthen and Newcastle Emlyn.
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The scheme aims to provide participants with a specific exercise programme to improve their health and lifestyle, provide advice on nutrition and then offer relevant advice to the needs of that individual, e.g. stress counselling, smoking cessation, alcohol and substance misuse e.t.c and refer to appropriate agencies.
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Our objectives are a follows:
1. To produce a 12-week personalised activity programme for adults aged 18 and above, identified as being at risk of Coronary Heart Disease or other medical conditions identified within the protocol.
2. To provide 2-3 sessions per week at the identified venue under adequately qualified supervision and to encourage 1 free activity per week, e.g. walking, home based exercise etc.
3. To target patients who have health risk factors which are amenable to exercise.4. To encourage physical activity within the general population using existing facilities within the county of Carmarthenshire .
6. To foster increased awareness about the benefits of physical activity and nutrition as part of a healthy lifestyle.
7. To monitor the uptake and compliance of the scheme at regularintervals.
8. To evaluate the health outcomes using the fitness indicators including pulse, BP, BMI etc
9. To link the scheme with other Health Improvement projects such as - smoking cessation, nutrition and dietary advice, stress counselling etc. dependant upon the needs of the individual participating in the scheme. -
General Practice surgeries are invited to refer these patients that are considered to be at risk of a coronary event and suitable to undertake physical activity. The referrals are sent to the GP Exercise Referral Team and clients will be allocated a time to meet the GP Exercise Referral Instructor on a one-to one basis to collect baseline measurements, assess the needs of the client and to determine a personalised activity programme. The one-to-one meetings with the instructor will take place at week one, week six and week twelve. After completing the Exercise Referral programme clients are encouraged to continue to adopt a healthy lifestyle.
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Click here to access the exercise referral form
Resources
If an individual is motivated to become more physically active, they may benefit from referral to a specialist scheme, particularly those at risk from CHD or who have experienced a coronary event. The "Vitality" GP Exercise Referral Scheme currently operates within the Llanelli locality, for this group of patients. Other leisure facilities in Carmarthenshire are in the process of training staff to deal with specific needs for such patients. For further information, advice and contacts regarding appropriately trained fitness staff serving your locality and facilities, please contact the Referral Scheme Co-ordinator on 01554 747516
The Health Promotion Service together with other partners, such as primary care teams, community groups and statutory organisations, are developing "Walking the Way to Health" schemes across Carmarthenshire. Details of developments within localities will be forwarded to your practice. For further information regarding Walking Schemes or Physical activity issues, please contact Liz Newbury-Davies Health Promotion Officer (Heart Health) at Carmarthenshire Local Health Board Offices on 01554 778593.
E mail: Liz.Newbury-Davies@nphs.wales.nhs.uk
For advice and information regarding a range of sporting or recreational activities within the county, (ranging from Bowls to Martial Arts and many more) please contact the Department of Recreation and Sport, Carmarthenshire County Council on 01554 747500 who can supply local contacts for patients interested in participating in such activities