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ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #22: Physical Activity, Part 4

Mar 9, 2014
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Sheri R. Colberg, PhD, and Michael C. Riddell, PhD

ADA-JDRF-Type-1-Diabetes-Sourcebook-image

EXERCISE WITH COMPLICATIONS OR OTHER HEALTH CONDITIONS: Relative and Absolute Contraindications

The ADA and others have stressed the importance of appropriate screening procedures to clear patients for participation in exercise.157–164 For patients with T1D, all of the diabetes-associated complications (microvascular and macrovascular disease) place the individual at a theoretically elevated risk for an adverse event caused by exercise, although actually documenting adverse events as a result of exercise in this population has been challenging.25 Nonetheless, a number of precautions are warranted.

Coronary artery disease or stroke. Due to their elevated risk for macrovascular and microvascular disease (see chapter 16), patients with T1D who have had diabetes >10–15 years should undergo screening before starting a new program of unaccustomed vigorous activity (>6 METs).25,165 However, no exercise restrictions should be placed on already active patients or on patients previously sedentary who are age <30 years or on patients age >30 years with no apparent complications. Pre-exercise screening is recommended for those who have been living with the disease for >10–15 years and who are age >30 years and should be conducted by a physician and or a qualified exercise professional (i.e., ACSM Certified Exercise Physiologist). Any symptoms of exercise intolerance (exhaustion, symptoms of poor perfusion, etc.) should be followed up, possibly with an exercise stress test or cardiac imaging or both. Traditional and nontraditional symptoms of cardiovascular disease requiring diagnostic follow-up are:

  • Difficulty completing usual tasks
  • Dyspnea with minimal exertion
  • Unusual lack of energy
  • Shoulder pain with a history similar to bursitis and related to activity
  • Dizziness with activity
  • Easy fatigability
  • Neck or jaw discomfort
  • Upper back pain

For previously sedentary persons with T1D age >30 years (and with diabetes duration ≥10 years) or with any diabetes-related complications (micro- or macrovascular) exercise programming of activities more vigorous than brisk walking should be suspended pending medical follow-up that may include exercise stress testing for the evaluation of CVD.166 If CVD is stable, then mild to moderate-intensity exercise may be considered safe and effective in limiting disease morbidity.

Since those with diabetes who are more physically active have much less risk for a cardiovascular event than those with disease who are sedentary, the consensus is that the risks of exercise are outweighed by the numerous benefits, as long as certain precautions are taken.25,167 It is important to note that not all persons with T1D should be considered at high risk for CVD, particularly if they are in good glycemic control.168  

Retinopathy. The effect of exercise on retinal damage (see chapter 16) in those with either background or proliferative retinopathy is unclear, but there is concern that increases in blood pressure or jarring movements, or both, at the latter stages of disease progression may facilitate retinal hemorrhage.169 During a 10-year, exercise-based outpatient program for individuals with diabetes (both T1D and T2D) who had multiple complications at baseline, there was a 10% occurrence of retinal hemorrhage temporally related to exercise (3 of 30 patients who had baseline retinopathy).170 It is important to note that events occurred only when the exercise was more vigorous than what had been prescribed by their exercise professional and the occurrences of retinal hemorrhage in nonactive patients with retinopathy was not provided for comparison.170

Other prospective cohort studies in humans with existing retinopathy have not shown an increased risk of retinopathy progression or of vitreous hemorrhage as a result of increased participation in team sports and exercise in patients with background retinopathy.159,171,172 Moreover, several cross-sectional 8,173 and two retrospective observational studies174,175 show no association between exercise participation and the risk of worsening retinopathy in people with T1D. Some evidence from one of these cross-sectional studies even supports the notion that increased physical activity participation might delay the development of retinopathy, at least in females.172 These limited data suggest that exercise participation does not influence the risk of developing diabetic retinopathy if exercise is performed appropriately (i.e., not causing an excessive hypertensive response). Nonetheless, because of the fear that an increase in blood pressure associated with heavy exercise might cause retinal hemorrhaging and since prolonged exercise might increase growth hormone levels, both of which are associated with the development of retinopathy, persons with advanced retinopathy are frequently advised to avoid strenuous activities that increase blood pressure above 170 mm Hg systolic.176,177

In a National Institutes of Health consensus panel report, it was stated that "activities that require straining and breath holding" increase ocular risk of retinal detachment and vitreous hemorrhage as a result of elevations in blood pressure.178 Accordingly, the panel does not endorse certain activities such as weight lifting for persons with diabetes with evidence of retinopathy. This expert opinion-based recommendation is controversial, however, since resistance exercise using moderate weight training (e.g., three sets at a moderate level using the major muscle groups) appears to be associated with lower blood pressure response compared to typical aerobic activities like stair climbing.96 Given the preceding evidence, authors of various organizations have generally recommended moderate-intensity exercise (aerobic and resistance) but advised against vigorous exercise for those with severe nonproliferative or proliferative retinopathy.158,163,177,179

Neuropathy (peripheral and autonomic) or amputation. Distal sensory polyneuropathy (see chapter 16) occurs in several motor and sensory nerves in patients with long-standing disease and may be associated with movement difficulties, weakness, pain, and the loss of peripheral sensation. Peripheral neuropathy is linked to increased risk of foot ulceration and poor wound healing, causing amputation. Several aspects of exercise safety are of consideration for people with neuropathy, including their cardiovascular impairment, their risk of foot ulcerations, and their risk of falls. Unfortunately, clinical trials measuring the beneficial effects and adverse events associated with exercise in patients with neuropathy are limited.

Increased physical activity participation appears to dramatically lower the risk of developing peripheral neuropathy.8,10 Little evidence proves that exercise worsens diabetic neuropathy. In fact, two studies observed that increased exercise participation actually decreased foot-ulceration risk in persons with diabetes who were also diagnosed with neuropathy.180,181 However, some laboratory-based evidence suggests that abrupt increases in activity may increase the short-term risk of ulceration because of increased plantar pressures.164,181 Moreover, with increased physical activity, there is likely an increased risk for falls and injury and, thus, supervised exercise may be advisable in higher risk individuals.

Nephropathy. Existing evidence does not support the avoidance of physical activity for patients with diabetic kidney disease (see chapter 16), although some precautions may be warranted.182,183 Those with early nephropathy, who typically have low exercise tolerance, should probably avoid vigorous exercise, although mild- to moderate-intensity exercise is thought to be beneficial.183 Individuals with end-stage renal disease have very low exercise tolerance, low aerobic capacity (Vo2max <20 ml × kg–1 × min–1), decreased cardiac output, blunted heart rate response to exercise, anemia, and decreased oxygen extraction.184 These individuals need special care when being prescribed exercise and should be under close supervision, although mild and moderate aerobic exercise done during dialysis treatments has shown to increase fitness levels and exercise compliance.185 Cardiovascular complications are also common in individuals with nephropathy, although little evidence exists that exercise triggers any adverse events.186–189 As special care may be needed in these individuals with advanced disease, including erythropoietin administration, supervised exercise programs are recommended for those with advanced kidney disease.25,186,188 A summary of the recommended pre-exercise assessment strategies for patients with T1D at different ages is found in Table 11.5.

SPECIAL CONSIDERATIONS
Hydration

Due to potentially greater water losses with hyperglycemia, exercisers with T1D must focus on staying adequately hydrated before, during, and after any physical activity.190 Starting several hours before exercise, individuals should take in normal amounts of fluids and meals to attain a state of euhydration prior to exercising, particularly if they have recently experienced hyperglycemia, either acutely or chronically.190 According to the American College of Sports Medicine, the goal of fluid intake during exercise is to prevent excessive dehydration (>2% body weight loss from water deficit) and electrolyte imbalances.191 Hydration state at the start of exercise, sweating rates, and environmental conditions all affect fluid requirements during physical activity.191 Individual sweat rates can be estimated by measuring body weight before and after exercise. Excessive weight loss indicates a dehydrated state and should be prevented, whereas weight gain from excess fluid intake during activities may lead to hyponatremia and should also be avoided.192 During exercise, consuming beverages containing electrolytes and carbohydrates can provide benefits over water alone under certain circumstances, such as when carbohydrate is needed to prevent hypoglycemia and during more prolonged activities.192–194 After exercise, the goal is simply to replace any fluid or electrolyte deficit, which can usually be accomplished with water intake and a healthy diet. Whole milk and sports drinks that are designed for both quick and long-lasting nutrient replenishment (including carbohydrates) can also be used by anyone with T1D to lower the risk of late-onset hypoglycemia associated with prior exercise.195,196

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