Type 2 Diabetes and Disabilities

Medical and Clinical Issues Affecting Physical Activity
Although complications are prevalent in type 2 diabetes (ADA, 1994), their existence is not a clinical contraindication for physical activity (see Table 3). The risks of worsening specific complications or provoking musculoskeletal injures in persons with type 2 diabetes are increased with physical activity (ADA, 1994; Ford & Herman, 1995). Hence, there are physical activity precautions and limitations for type 2 diabetics who have disease-related complications (ACSM, 1995; Gordon, 1995).

Table 3 Recommendations and Precautions for Persons with Disease-Related Complications
Complication               Recommendation                         Precaution                               Comments

Retinopathy                     Lower intensity activity                   Avoid -                                     MD approval
(eye disease;                    keep blood pressure (BP) lower      strenuous overhead activities     for activity
leads to blindness)                                                                  Val Salva during activity

Neuropathy
       Automic                    Low-level daily activities                 Use RPE for intensity               MD approval
                                                                                                                                                  for activity
      Peripheral                 Non-weight-bearing activity             Loss of feeling in feet -            Check feet for
                                                                                                 avoid irritations                        undetected sores

Nephropathy                    Low intensity activities                    Avoid -                                     MD approval
(kidney disease)                                                                       excessive rise in BP                  BP monitoring may
                                                                                                                                                  be necessary

Peripheral Vascular          Lower intensity activities;                Claudication pain is limiting -    Activity is performed
Disease (PVD)                 alternate between weight- and         use adequate rest intervals          to pain tolerance
                                         non-weight-bearing                         with weight-bearing activity       of client

Hypoglycemia
       Exercise-induced hypoglycemia (low blood glucose) can occur in persons with type 2 diabetes; however, it is most common in insulin-requiring diabetics. To minimize the occurrence of low blood glucose, self-blood glucose monitoring (SBGM) is recommended for persons with type 2 diabetes who engage in physical activity, especially during the initial activity sessions (ACSM, 1995; Gordon, 1995). Moreover, glucose monitoring is appropriate before and after an exercise bout.
       Given the knowledge and understanding of glucose levels, type 2 diabetics can take an appropriate route of action by increasing carbohydrate consumption (or reducing medications). Through blood glucose monitoring, the frequency of hypoglycemic events can be lessened.
       The time of day for activity is extremely important to avoid possible hypoglycemia, especially for insulin-requiring diabetics. Given the time of insulin administration and nutrient intake, it has been suggested that the best time for insulin-requiring diabetics to exercise is 1-2 hours after breakfast, or in the morning hours. However, individualizing the program and affording a compatible physical activity schedule with the client's lifestyle are important to consider when developing a physical activity program.

Hyperglycemia
When pre-exercise glucose levels exceed 250 mg/dl, exercise should be postponed, as this glucose level, hyperglycemia, is reflective of poor control (ACSM, 1995). If a log of blood glucose values is kept, glucose fluctuations can be evaluated by the management team to address better ways of avoiding such occurrences in the future. When the blood glucose level is elevated, administration of an appropriate medication dosage is recommended.



Pragmatic Recommendations for Type 2 Diabetics Before Physical Activity
There are numerous factors for type 2 diabetics to consider before engaging in physical activity. Various pragmatic recommendations provide an element of safety before, during, and after any physical exertion, and should be routinely practiced (see Table 4). The recommendations shown in Table 3 are intended for professionals to suggest to clients with type 2 diabetes.
In summary, professionals who develop and supervise activity program development for persons with disabilities should be aware that clients will commonly exhibit type 2 diabetes. It is crucial to encourage all clients to engage in physical activity, regardless of their disabilities. Physical activity is a key therapeutic element for lessening risk for chronic conditions, as well as maintaining health and quality of life.

Table 4
Recommendations for Persons with Type 2 Diabetes When Participating in Physical Activity
Self-Blood Glucose Monitoring (SBGM) -
Perform before and after each physical activity session. Excellent cognitive training for diabetics to understand individual glucose response to physical activity. It is important to ensure that blood glucose is in relatively good control before beginning higher intensity physical activity. If blood glucose is:
· > 250 mg/dl, higher intensity physical activity should be postponed;
· < 100 mg/dl, eat a snack consisting of carbohydrates;
· between 100-250 mg/dl, physical activity can be performed.

Keep a Daily Log -
Record value and time of day the SBGM is performed and amount of any pharmacologic agent (i.e., oral drugs or insulin). Also, include approximate duration (minutes) and effort (your perception: scale 1) of the activity session. This will aid the diabetic in understanding the type of response to possibly expect from specific physical activity bouts.

Plan for an Exercise Session -
· how much (i.e., time and intensity) activity is anticipated;
· if needed, carry along extra carbohydrate feedings.

Be Active with a Partner -
Affords a support system for the physical activity habit. Initially, diabetics should exercise with a partner until glucose response is known. Ideally, a partner who accompanies the physically active diabetic is a source of social support and encourages continued participation in this healthy lifestyle.

Wear a Diabetes I.D. -
Never leave home without it. Hypoglycemia, or other problems, may arise that require an understanding of the condition.

Wear Good Shoes -
Proper-fitting and comfortable footwear can minimize foot irritations and sores, and reduce the occurrence of orthopedic injuries to the foot and lower leg.

Practice Good Hygiene -
Always take extra care to inspect feet for any irritated spots to prevent possible infection. Tend to all sores immediately. Report hard-to-heal sores to your physician. Prevent irritations when physically active by using Vaseline on feet and wearing socks inside-out.



Selected References
American College of Sports Medicine [ACSM] (1995). Guidelines to exercise testing and exercise prescriptions     (5th ed.). Philadelphia:      William & Wilkins.
American Diabetes Association [ADA] (1994). Medical management of non-insulin-dependent (type 2) diabetes (3rd ed.). Alexandria, VA:      Author.
Ford, E.S., & Herman, W.H. (1995). Leisure-time physical activity patterns in the U.S. diabetic population: Findings from the 1990 national      health interview survey-health promotion and disease prevention supplement. Diabetes Care, 18, 27-33.
Gordon, N. (1995) The exercise prescription. In: The health professional's guide to diabetes and exercise (71-82). Alexandria, VA: American      Diabetes Association.
Graham, C., & Lasko-McCarthey, P. (1990). Exercise options for persons with diabetic complications. Diabetes Educator, 16, 212-20.
Heath, G.W., & Fentem, F.H. (1997). Physical activity among persons with disabilities-a public health perspective (195-234). In: J.P. Holloszy      (Ed.) Exercise and Sports Science Review, 25. Philadelphia, PA: Williams & Wilkinson.
U.S. Department of Health and Human Services (USDHHS) (1996). Physical activity and health: A report of the Surgeon General, Atlanta, GA:      U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention      and Health Promotion.
Vinik, A.I. Neuropathy (1995). In: The health professional's guide to diabetes and exercise (183-97). Alexandria, VA: American Diabetes      Association.
Larry Verity is a professor of exercise & nutritional sciences at San Diego State University. In addition, he is a fellow in the American College of Sports Medicine, as well as a certified exercise specialist and the former Director of the Adult Fitness Program at SDSU. His primary area of research is in diabetes and exercise in which he is recognized as a leading authority in the field.
Peter Aufsesser is a professor of exercise & nutritional sciences at San Diego State University and the founder and Director of the Fitness Clinic for Individuals with Disabilities.
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