Considering the increasing epidemic of type 2 diabetes in adults and the increasing numbers of overweight and obese individuals, it is important for clinicians to find ways to reduce the cardiovascular complications of diabetes. “Exercise has been established as an important way to reduce the impact of diabetes-related problems,” says Todd D. Miller, MD, FACC, FAHA. “When combined with a healthy diet, exercise can prevent or slow the development of type 2 diabetes and produce clinically significant improvements in glucose control and cardiovascular risk factors.”
New Recommendations Released
In the June 30, 2009 issue of Circulation, the American Heart Association released a scientific statement on exercise training for type 2 diabetes, with a concentration on reducing cardiovascular risk. Dr. Miller, who co-authored the statement, says the document emphasizes the importance of exercise advice from primary care physicians (PCPs) and other providers. “Patients should work with their providers to establish effective exercise regimens,” he says. “PCPs and other caregivers need to prescribe specific exercise routines in order to improve cardiovascular health and metabolic control.”
According to the statement, patients with diabetes are recommended to get at least 150 min/week of moderate-intensity exercise, 90 min/week of vigorous-intensity exercise, or some combination of the two to improve cardiovascular risk (Table 1). Patients should exercise on at least 3 non-consecutive days each week to maximize benefits, and individual sessions should be at least 10 minutes each or longer. The statement also encourages that patients undertake moderate- to high-intensity resistance training. “These guidelines can be achieved with varying contributions of moderate-to-vigorous cardiorespiratory exercise,” Dr. Miller notes. “Physicians should recognize that their focus should primarily be to improve conditioning rather than to lose weight, and this message should be conveyed to patients. Weight loss is desirable, but using exercise alone as a means to weight loss would require substantially more exercise than what this statement recommends. Even if patients can’t achieve the recommended levels of exercise, some benefits with regard to diabetes and cardiovascular risk are still likely to occur. Reductions in risk associated with limited exercise are likely to be better for patients than remaining completely sedentary.”
Approaches to Adherence
Exercise counseling is recommended so that physicians can assess and adjust levels of physical activity and provide motivation and support. “Research shows that advice received from PCPs is likely to be followed,” Dr. Miller says. “PCPs, physician assistants, nurses, diabetes counselors, and other healthcare providers should collaborate to play a role by giving advice about physical activity during every encounter with patients who have diabetes. Unfortunately, many providers lack specific guidance on how to prescribe exercise training programs. If providers are unsure, they should refer patients to clinical exercise physiologists who have the specific skills and knowledge to apply exercise training principles to patients with diabetes.”
In addition to counseling, patient commitment to exercise training is paramount to adherence. “Patients need to exhibit a willingness to change their ways by preparing for exercise and then complete and maintain their training programs,” says Dr. Miller. “Physicians need to pay attention to their competence, motivation, past experiences, and many other considerations when prescribing exercise programs [Table 2]. Ongoing, individual counseling should be used in conjunction with exercise consultations, group support, and other strategies that have been shown to be effective for adhering to exercise regimens.”
The use of internet-based programs and telephone exercise counseling has also been shown in the literature to be of benefit for sustaining adherence to training regimens. “These strategies appear to be reasonably effective in maintaining exercise compliance, improving glycemic control, and enhancing functional capacity in patients with diabetes,” Dr. Miller adds. “Home-based exercise training with counseling is another strategy that offers convenience, flexibility, cost-effectiveness, and greater general appeal, but patients will still require ongoing counseling, supervision, support, and motivation.”
Educate Patients
Many individuals, particularly older adults with diabetes, are deconditioned and have limited strength and flexibility. Their engagement in physical activity may be more challenging because of comorbidities. As such, Dr. Miller says all patients with diabetes should be educated on how to prepare for exercise; the frequency, intensity, and duration at which it should be performed; the types of exercise to be performed; and typical and atypical symptoms of problems that may arise. “Exercise training in patients with diabetes is feasible, well tolerated, and beneficial,” he says, “but it’s important to remember that individualized exercise prescriptions are needed. This strategy can help account for cardiac and non-cardiac considerations. We need to implement exercise training regimens that will last for the long term in order to truly reduce cardiovascular risks in patients with diabetes.”
Todd D. Miller, MD, FACC, FAHA, has indicated to Physician’s Weekly that he has received research grants from Boehringer Ingelheim, Boston Scientific, Bristol Myers Squibb, KAI Pharmaceuticals, Lantheus Medical Imaging, Molecular Insight Pharmaceuticals, Radiant Medicals, Spectranetics, and TargeGen. He has also been a consultant or worked on the advisory board for TherOx, Inc. and The Medicines Company.
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