July 2017 Issue

Diabetes Management & Nutrition Guide: The Latest Physical Activity Recommendations
By Sherry Coleman Collins, MS, RDN, LD
Today's Dietitian
Vol. 19, No. 7, P. 44

Here's an overview of the new guidelines and strategies for counseling and motivating patients to move more.

Diabetes is estimated to affect approximately 29 million Americans, with one in four unaware that they have diabetes. Another 86 million adults may have prediabetes, and up to 30% of them will develop full-blown diabetes within five years. The total burden of diabetes on the health care system and economy could be as high as $245 billion. Those with diabetes are at higher risk of blindness, kidney failure, heart disease, stroke, and amputations, and they face a 50% greater mortality risk due to their disease.1 Slowing the progression of diabetes, reducing complications, and improving blood glucose management will have a long-lasting and significant impact.

Dietary and lifestyle interventions are an essential part of preventing and managing diabetes. It's known that regular exercise has a positive impact on overall health, reducing the risk of developing prediabetes and the progression to type 2 diabetes. Exercise increases insulin sensitivity and blood circulation and reduces the risk of cardiovascular disease and stroke.2 For these reasons, the American Diabetes Association (ADA) has long had a position statement on physical activity to encourage practitioners to discuss them with their patients who have diabetes so they'll begin including physical activity in their lives. However, late last year, the ADA updated its guidelines with some surprising new recommendations in "Physical Activity/Exercise and Diabetes: A Position Statement of the American Diabetes Association."

Why the Changes?
According to lead author Sheri Colberg-Ochs, PhD, FACSM, professor emerita and an exercise science and research professor at Old Dominion University in Norfolk, Virginia, the previous recommendations from the ADA had focused only on type 2 diabetes and physical activity, but there's evidence for broader guidance. She says the new position statement "includes all types of diabetes (type 1, type 2, and gestational) and prediabetes … and emphasizes that people with diabetes can benefit from doing cardiovascular, resistance, flexibility, and balance training (the latter for those over age 40 or with neuropathy). Exercising safely and effectively with various health complications also is addressed." Physical activity and diabetes experts from the United States, Australia, and Canada developed the new guidelines. In short, the new position statement provides more complete guidance.

More Movement, More Often, With More Variety
According to Newport News, Virginia-based dietitian and certified diabetes educator Jill Weisenberger, MS, RDN, CDE, FAND, CHWC, "The depth of these recommendations makes them unique. Not only do they cover recommendations for people with various types of diabetes and stages of life, but they also detail how to get started and how to progress with various types of exercises." One of the significant changes is in recommending that people with diabetes get up and engage in light activity for three minutes every 30 minutes to break up sedentary time. This updated guidance was based on research that shows the increased health risks related to long stretches of sedentary behavior and is a change from the previous recommendation to move every 90 minutes. It's important to note that this is in addition to the recommendations for regular structured exercise. To help her clients implement this recommendation, Weisenberger, who also is author of Diabetes Weight Loss — Week by Week: A Safe, Effective Method for Losing Weight and Improving Your Health and 21 Things You Need to Know About Diabetes and Your Heart, has her patients run through their day, then brainstorm a list of solutions to increase activity. "One patient has decided to stand and walk around her office each time she drinks something, which is many times per day. Others have decided to stop calling and e-mailing coworkers and walk to their desks instead," she says.

In addition to the recommendation to move more throughout the day, the new guidelines also suggest not allowing more than two days to elapse between exercise sessions. A goal of moderate to vigorous aerobic activity for 150 minutes per week for adults and 60 minutes per week for children and adolescents are the goals set for structured exercise. Shorter duration activities, such as high-intensity interval training, are mentioned as a potential way for younger and more physically fit people with diabetes to meet their activity goals in less time; however, supervision is recommended, as these may not be appropriate for everyone with the disease. Children and adolescents also should include muscle and bone strengthening activities at least three days per week, while adults also should do resistance training two to three nonconsecutive days per week. Older adults with diabetes may benefit from two or three sessions per week of flexibility and balance training, such as yoga or tai chi. The guidelines also state that people with diabetes may benefit from working with a qualified physical activity and exercise expert.

Nutrition also is addressed in the new guidelines. Dietary changes, such as calorie reduction and increasing fiber, are suggested to assist with weight reduction of 5% to 7% of total body weight to prevent or delay type 2 diabetes in those at high risk, such as those with prediabetes. Adjustments to carbohydrate consumption, either increasing or decreasing consumption before or after, also may be necessary based on individual blood glucose response to exercise and activity.

Special Considerations
There's no doubt that being appropriately physically active has benefits for every population. However, there are some groups with diabetes who may need additional help to safely engage in physical activity. Because the evidence doesn't support that those with asymptomatic diabetes require special medical clearance in advance of beginning low or moderate physical activity, the guidelines don't suggest this for all patients. However, those at higher risk of complications or those with poorly controlled diabetes may benefit from a visit to their health care provider before increasing the intensity of physical activity.

Individuals with type 1 diabetes can respond in variable ways to different types of stress, including physical activity. Blood glucose should be carefully and frequently monitored and adjustments to insulin or carbohydrate intake should be made based on an individual's needs. Monitoring before the start of activity and during exercise should be done to prevent exercise-induced hypoglycemia. In fact, Colberg-Ochs says, "Being active is always going to be trickier for insulin users to manage, and [RDNs] should be aware of how diet and insulin can be balanced to prevent hypoglycemia (and hyperglycemia) in people with diabetes."

Pregnancy places additional stress on women with diabetes, but being physically fit can help. The new position statement recommends regular physical activity before and during pregnancy. For those at risk of gestational diabetes, 20 to 30 minutes of moderately intense exercise should be recommended on most or all days of the week.

Those experiencing complications because of diabetes may be worried about increasing or beginning an exercise regimen. It's wise to encourage them to discuss these concerns with their health care provider, although most can safely exercise when they take precautions. For instance, those with peripheral neuropathy should protect their feet to prevent foot problems such as ulcerations, which may increase risk of amputations. And regular stretching may help manage joint changes related to diabetes. In addition, exercise doesn't make kidney disease worse, even in those requiring dialysis. However, certain activities that may increase eye pressure or include excessive jarring actions, such as vigorous aerobic activity, may not be appropriate for individuals with diabetic retinopathy.

Overcoming Barriers to Adopting Change
The guidelines suggest that targeted behavior-change strategies should be used to increase physical activity. Yet, adopting healthy habits can be challenging. The position statement suggests helping clients set attainable goals and using technology as important strategies to employ.

Focus on the Benefits
To encourage her patients, Weisenberger reminds them that every time they exercise, they improve insulin sensitivity for two to 72 hours. "It helps to focus on exercise for health benefits and mood changes, and completely separate it from weight loss," she says.

Likewise, Vandana Sheth, RDN, CDE, a Los Angeles-based diabetes expert and spokesperson for the Academy of Nutrition and Dietetics, tells patients, "When we move, it not only helps your blood sugar, it can also help you become more alert. Taking regular and frequent breaks during your workday can positively impact your focus and creativity."

Use Technology
Technology can be an amazing time-saver. Taking advantage of phone apps, wearable technology (such as FitBit), and automatic reminders on computers can help individuals manage their time when it comes to instituting the new recommendations for physical activity. "When discussing these recommendations with clients, it's important to customize them so that they're practical," Sheth says. "I often suggest clients use a reminder on their phones or calendars as a tool to get them to move. It will automatically provide motivation to move."

Keep It Simple
Toby Smithson, MS, RDN, LD, CDE, coauthor of Diabetes Meal Planning and Nutrition for Dummies and founder of DiabetesEveryDay.com, suggests breaking the recommendations into smaller, easy to implement actions. "When you have diabetes, you're already multitasking. Adding more activity recommendations adds more tasks, so it may feel overwhelming for people with diabetes, especially if they're sedentary." She recommends setting SMART (specific, measurable, achievable, relevant, time bound) goals, providing a fun list of activities to do during the three-minute activity breaks throughout the day (see sidebar), and partnering with an exercise physiologist for creative ways to get clients moving.

Skill and Partnership Are Key
Motivating people with diabetes to adopt these latest recommendations for physical activity can have a positive impact on them. Weisenberger cautions that even though the position statement provides great detail about managing diabetes, "practitioners need to fully understand the physiology of diabetes to implement these guidelines with skill." Partnering with a certified exercise professional and the patient's health care provider can ensure the safe and effective inclusion of regular physical activity. Colberg-Ochs sums it up with a clear goal: "If dietitians can simply get people up and moving more, their health will benefit."

— Sherry Coleman Collins, MS, RDN, LD, is president of Southern Fried Nutrition Services in Atlanta, specializing in food allergies and sensitivities, digestive disorders, and nutrition communications. Find her on social media @DietitianSherry and at www.southernfriednutrition.com.

References
1. Diabetes latest. Centers for Disease Control and Prevention website. https://www.cdc.gov/features/diabetesfactsheet/. Updated June 17, 2014. Accessed on May 6, 2017.

2. Colberg SR, Sigal RJ, Yardley JE, et al. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065-2079.