15th anniversary graphic 1984 - 1999PALAESTRA: Forum Of Sport, Physical Education & Recreation For Those With Disabilities logo

 

Fall 1999
Volume 15

Number 4
Issued Quarterly

Articles featured in this issue:
 
(Currently featured article from this issue follows.)
 
Type 2 Diabetes and Disabilities - A Dangerous Duo:
What are the Recommendations?
 
by Larry S. Verity and Peter M. Aufsesser
 
exercise picture
 
       

Professionals must realize that type 2 diabetes mellitus co-exists with many persons who have physical, neurological, or neuromuscular limitations and disabilities. As the duration of diagnosed diabetes increases, there is greater likelihood that nerve, eye, or physical impairments will occur that lead to disabilities (American Diabetes Association, 1995).


       Conversely, the longer a person lives with a disability, there is greater likelihood that type 2 diabetes will develop (Heath & Fentem, 1997; U.S. Dept. of Health & Human Services, 1996). Such a relationship between type 2 diabetes and disabilities suggests that both type 2 diabetes and disabilities result in very similar long-term health risks, as well as outcomes on health and quality of living.
       In general, poor diabetes control can contribute to the progression of disease-related complications resulting in eye, nerve, and muscular disabilities. Additionally, about 50% of all non-traumatic amputations are related to diabetes (ADA, 1994); hence, type 2 diabetes poses a very real threat to one's livelihood and quality of life. Interestingly, those with physical disabilities and/or type 2 diabetes tend to be less active, have a lower work capacity, and be at greater risk for chronic diseases than their non-disabled counterparts (Heath & Fentem, 1997). Moreover, physical inactivity accelerates the loss of function in all persons, especially a reduction in muscular strength and functional range of motion. Loss of these important musculoskeletal functions has significant relevance to activities of daily living (ADL) and to ultimate loss of independence, or autonomy, in persons with physical disabilities (Heath & Fentem, 1997; USDHHS, 1996).
       Given that physical inactivity increases the risk for various health-related problems (USDHHS, 1996), including cardiovascular heart disease, high blood pressure, and obesity, the role of an active lifestyle among persons with physical disabilities and type 2 diabetes may be central to their health and well-being. The primary challenge for exercise professionals is persuading persons with disabilities to adopt more active lifestyles.
       There are two primary classifications of diabetes mellitus, namely, type 1 and type 2. A comparison of differences between persons with type1 diabetes and type 2 diabetes is presented in Table1 . Regardless of the type of diabetes mellitus, both result in an elevation of blood glucose, increased risk for other chronic diseases, and increased likelihood for diabetes-related complications. Interestingly, the long-term health consequences of type 2 diabetes can be favorably modified through healthier lifestyles, including careful nutritional habits, medications (e.g., oral drugs or insulin), physical activity, and daily monitoring of blood glucose (ADA, 1994)
 
Table 1
Characteristic Differences Between Type 1 and Type 2 Diabetes                                          
 Characteristic                            Type 1 Diabetes                           Type 2 Diabetes
Former Abbreviations               IDDM, juvenile-onset                     NIDDM, adult-onset           
Common Synonyms                   Insulin dependent                           Non-insulin dependent
Age at Onset                                Usually, < 20 years                         Usually, > 40 years
Body Weight                                Normal weight                                Overweight
Body Fat                                       Normal                                           ~80% are obese
% Prevalence                               5-10%                                             90-95%
Insulin Injections Required      100%                                               ~40% require insulin
Primary Cause                             Loss of insulin production             Loss of insulin action via
                                                       via autoimmune dysfunction          lifestyle, obesity, age
Family History                             Not very strong history                  Strong relationship to onset
 
What is Type 2 Diabetes Mellitus?
       It is a chronic disease whose onset is related to several factors, including older age, female gender, obesity, and physical inactivity. Current estimates suggest that type 2 diabetes comprises about 90-95% of persons with diabetes. In addition, certain ethnic minorities (e.g., Pima Indians, Mexican-Americans, and African Americans) are more prone to this type of diabetes than Caucasians (ADA, 1994)
       In and of itself, diabetes is the sixth leading cause of limitations in non-institutionalized United States adults (Heath & Fentem, 1997) and a primary reason for lower limb amputations (ADA, 1994). When type 2 diabetes becomes part of the health profile of an individual with a disability, there is increased risk for other conditions (e.g., high blood pressure and heart disease) and progression of complications (e.g., nerve, kidney, and eye diseases) that can be minimized and/or prevented through effective management.
 
What is the Recommended Management Strategy for Type 2 Diabetes?
       Current recommendations stress the need for a team approach to effectively manage type 2 diabetes. Medical management of type 2 diabetes is essential, along with nutrition counseling, medication use, behavior change therapy, and physical activity as the focuses of therapeutic intervention. There are identifiable limitations (e.g., presence of complications leading to impairment or disability) and precautions (e.g., degree of metabolic control) to be addressed when developing a physical activity program. Of utmost importance to professionals is that persons with type 2 diabetes are less likely to participate in regular physical activity than their non-diabetic counterparts (Ford & Herman, 1995), which poses a greater challenge in developing the activity program.
       Prior to recommending physical activity, it is essential for persons with type 2 diabetes to obtain physician approval (ACSM, 1995; Gordon, 1995). In order for a safe and effective individualized activity program to be developed, medical information regarding the health status of the individual is crucial.
       There are many factors to address before developing an activity program. When medical approval is recommended, this should focus on how well the client controls his/her glucose (e.g., reflected by glycosylated hemoglobin [HbA1c]), prescribed medications, physical limitations with respect to joint mobility common to diabetes, and any impairments or disabilities related to the severity of complications. Given the age of the individual and duration of diabetes, the physician may recommend that a stress test be performed before safely participating in physical activity.
       The rationale for recommending a stress test electrocardiography on persons who meet these criteria is to assess cardiovascular and respiratory systems, as the risk for cardiovascular heart disease is increased with type 2 diabetes (ADA, 1994). Moreover, the stress test electrocardiography will identify safe intensity limits for persons with or without autonomic neuropathy.
       Objective medical information (e.g., clinical health status, presence of complications) is a prerequisite for developing an individualized physical activity program. Given that most persons with type 2 diabetes are overweight and/or obese, information regarding personal goals and interests are central to a successful program.
 
Physical Activity Program Development
       Development of the physical activity program should be based on medical recommendations expressed by the physician and limitations, or disabilities identified. Moreover, any activity program must take into consideration personal interests, along with past and/or present habits. Individual goals and needs of a physical activity program are critical to determine whether the activity habit will be sustained, especially in obese, type 2 diabetics. In addition, blood glucose monitoring before and after physical activity at the commencement of the program is essential to ensure safe and effective physical activity.
 
Recommended Physical Activity Programs for Persons with Type 2 Diabetes
      Traditional physical activity recommendations for persons with type 2 diabetes focus on increased energy expenditure for those without significant limitations or complications. Irrespective of traditional recommendations, adapted fitness professionals should encourage clients who have co-existing type 2 diabetes and disabilities to increase weekly energy expenditure on a regular basis to aid in improved weight management (see Table 2). Especially important, it is suggested that the frequency, duration, and mode of physical activity for persons with type 2 diabetes be identified (ACSM, 1995; Gordon, 1995).
 
Table 2
How Much Activity is Recommended
                           Recommendations                                      Comment
Frequency         3 days/wk minimum                                      Household chores may be used for activity                            5 days/wk preferable                                      Safe and effective for most clients                         Intensity            Low-to-moderate level (may require MD)     Safe and effective for most clients
                           Use RPE (10-14 on 6-20 scale)                     Good to know how hard client perceives activity
Time                  30-60 minutes                                                Goal: 30 minutes each session
                           continuous or                                                 Continuous: no stopping
                           discontinuous activity                                     Discontinuous: three 10-minute sessions per day
Type                  Aerobic                                                           Most health benefits are aerobic-related
                           Include resistance activities                             Resistance training maintains muscle function -
                                                                                                  lessens dependence
 
Medical and Clinical Issues Affecting Physical Activity (article cont'd)
       
     

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