General practice management of type 2 diabetes


Physical activity
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Recommendations

Reference

Grade*

People with type 2 diabetes of all ages benefit from accumulating 30 minutes or more of moderate physical activity on most, if not all, days of the week

64
Briffa T et al, 2006

B

Exercise and physical activity (involving aerobic and/or resistance exercise) should be performed on a regular basis

65
SIGN, 2014

D

*Refer to Summary, explanation and source of recommendations for an explanation of the level of evidence and grade of evidence


Clinical context


Exercise is regarded as one of the cornerstones for diabetes management, and while generic physical activity can have a favourable impact on improving glycaemic control, reducing CDV risk and reducing overall mortality,66, 67 more specialised and individualised exercise prescription can achieve superior benefits.66 Aerobic exercise has been shown to achieve a similar reduction on HbA1c as either metformin or a sulphonylurea (ie a reduction of 0.73% with exercise and 0.9% with single medication). Resistance training has a smaller effect. For more information on exercise and type 2 diabetes, visit  the HANDI exercise for type 2 diabetes page.

Regular physical activity improves metabolic control, reduces CVD risks and can reduce the risk of developing type 2 diabetes.68 Low-level aerobic exercise (eg brisk walking for half an hour per day) and physical resistance training improves glucose tolerance, energy expenditure, feeling of wellbeing and work capacity, and improves BP, lipid profiles and mood.


In practice


The goal is for patients to undertake aerobic training that brings the heart rate up to 55–69% of maximum (208 – 0.7 x age [years] = maximum beats per minute)69,70 for a minimum of 30 minutes on most, if not all days of the week (≥150 minutes/week). This establishes and maintains fitness and aerobic capacity.

Evidence indicates that people with diabetes, IFG and/or IGT should aim for a minimum of 210 minutes per week of moderate intensity exercise or 125 minutes per week of vigorous intensity exercise, and no more than two consecutive days without training. For more information on resistance training, visit  the HANDI exercise for type 2 diabetes page.

Note that setting short-term, gradually increasing goals may assist the patient in achieving goals. Evidence suggests that multidisciplinary and integrated care teams are best practice in the management of type 2 diabetes, preventing and decreasing the impact of complications and comorbidities, resulting in healthcare cost savings.67 Groupbased training that facilitates self management in people with type 2 diabetes is effective in improving FBG levels, HbA1c and diabetes knowledge, and in reducing systolic blood pressure (SBP) levels, body weight and the requirement for diabetes medication.66

People requiring insulin or those treated with sulphonylureas need to be aware of potential delayed effects of physical activity on BGLs – in particular delayed hypoglycaemia 6–12 hours after cessation of the activity.

People with diabetes need to be advised to moderate or cease their activity if they develop cardiovascular symptoms or feel unwell. Patients with claudication need to be encouraged to continue physical activity under appropriate clinical supervision.

When advising on physical activity, the GP should explain the:

  • risks and benefits of physical activity for the individual
  • importance of varying intensity of exercise levels
  • importance of following the chest pain/discomfort and/or diabetes symptom management plan.64

Clinical advice should be given to stop physical activity if the patient experiences symptoms of hypoglycaemia and to discontinue further physical activity until reviewed by their GP.

General physical activity safety advice for people with diabetes:

  • Instruct patients to check their BGL before, during and after prolonged physical activity if using insulin or sulphonylureas. Additional carbohydrate foods and medications adjustments may be required depending on the patient’s BGLs.
  • Advise patients that if their pre-exercise BGL is <5 mmol/L, they are at risk of a hypoglycaemic episode during or after exercise, and to have access to additional carbohydrates as per the advice of their CDE or APD. Delayed hypoglycaemia may occur up to 24 hours post-exercise.
  • Advise patients on how to recognise, prevent or manage hypoglycaemic events, including potential post-exercise hypoglycaemia (ie need for carbohydrates or medication adjustment).
  • Advise patients to carry a rapid-acting glucose source at all times (eg jelly beans, or glucose gel/drink).
  • Advise patients to wear correct supportive footwear – especially if there is neuropathy, vascular disease, abnormal foot structure or previous foot ulcer(s), in which case the advice of a podiatrist with an interest in high-risk feet should be sought. This advice would also include the appropriateness of ‘jolting’ exercises such as running, skipping and jumping.
  • Advise patients to check their feet daily and after physical activity for blisters, warm areas or redness.

When prescribing a physical activity program, the GP should be aware of the following:

  • A careful history should be taken.
  • Special attention needs to be paid to exertion-induced symptoms, chest or abdominal discomfort, claudication or syncope.
  • People with type 2 diabetes frequently have silent macrovascular disease.
  • For patients with hypertrophic obstructive cardiomyopathy (HOCM), heavy weightlifting and high-intensity aerobic exercise are not recommended.*
  • For patients with long QT syndrome, exercise may trigger a cardiac arrhythmic event.*
  • Vigorous exercise is contraindicated for those with proliferative retinopathy, and for three months after laser retinal treatment.*
  • Exercise may be relatively contraindicated in patients with peripheral neuropathy, a history of recurrent falls or uncontrolled hypertension.*
  • Recommendation for referral to an AEP should be considered.

*From The Royal Australian College of General Practitioners. HANDI interventions – Exercise: Type 2 diabetes. East Melbourne, Vic: RACGP, 2015. 

Screening with a stress electrocardiogram (ECG) is not indicated in asymptomatic individuals, but any symptoms suggestive of CVD need to be actively investigated.
 

ABORIGINAL AND TORRES STRAIT ISLANDER POINT

Many Aboriginal and Torres Strait Islander peoples are involved in physically demanding sporting and cultural activities, although, overall, Aboriginal and Torres Strait Islander peoples are not more physically active than non-Indigenous Australians.
GPs should be aware of activities that are affordable, appropriate and accessible for their Aboriginal and Torres Strait Islander patients, which may be run by local community groups.
Aboriginal and Torres Strait Islander peoples may prefer exercise and physical activities that are culturally, socially and economically meaningful. Such activities or other cultural activities may not be described as ‘exercise’ or ‘physical activity’, yet be of significant health and social benefit. A careful history in the context of a trusting doctor–patient relationship may bring about better understanding and opportunity.


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  2. Ryden L, Grant PJ, Anker SD, et al. ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). Eur Heart J 2013;34(39):3035–87.
  3. Department of Health. Australia’s physical activity & sedentary behaviour guidelines for adults (18–64 years). Canberra: DOH, 2014.
  4. Tanaka H, Monahan KD, Seals DR. Age-predicted maximal heart rate revisited. J Am Coll Cardiol 2001;37(1):153–56.
  5. Gellish RL, Goslin BR, Olson RE, McDonald A, Russi GD, Moudgil VK. Longitudinal modeling of the relationship between age and maximal heart rate. Med Sci Sports Exerc 2007;39(5):822–29.