When prescribing exercise or physical activity for a person with diabetes (PWD), diabetes educators should be specific. Research shows that an individual is more likely to perform exercise as recommended when those recommendations are specific. We give specifics when educating about medications, meal planning and blood glucose monitoring (i.e., how much and how often). Why would it be different with exercise? An individualized exercise or physical activity plan can be made specific by using the FITT Principle where F=frequency, I=intensity, T=type and T=time.
• If the person can not only talk, but also sing, the exercise is considered light intensity. This is useful when a person is getting started with exercise or if they have health concerns making moderate exercise unsafe.
This simple talk test method for determining exercise intensity has been compared to exercise tests where heart rate is monitored and has been determined to be safe and accurate. In fact, if a person is taking a beta blocker medication, it is generally safer than monitoring of heart rate (which is blunted by the medication). Obviously, this test doesn’t work in all situations, for example when swimming. In this case, a person can determine their intensity by doing water exercise and comparing their effort to how they feel when swimming.
So, when prescribing exercise or physical activity for a PWD, let’s be specific with exercise intensity and teach the talk test.
In my next blogs, I will review the specifics of frequency, type and time of exercise so stay tuned!
Recently, I received an email from Diabetes Care about articles published ahead of print. My eye was drawn to read a position statement of the American Diabetes Association (ADA) on type 1 diabetes. In a 20-page publication, Chiang and colleagues provided background information and clinical guidance for the management of individuals with type 1 diabetes from infancy to an older age.
Here are some highlights from the article:
- Pancreatic autoantibodies should be used to confirm the diagnosis of type 1 diabetes. Since my practice site is located in a rural area, I have not recommended obtaining these laboratory tests, but most commercial laboratories do not have reliably sensitive or specific assays for certain autoantibodies.
- As recommended in the 2014 ADA guidelines, relatives of patients with type 1 diabetes should be referred to a clinical research study. You can refer to sites by the National Institute of Health and Juvenile Diabetes Research Foundation for research information and location of centers.
- There is a lot of great information about development issues (Table 2), clinical evaluation (Table 4), and DSME content (Table 6) for patients with type 1 diabetes from infancy to an older age. This section would be a great topic for discussion and presentation at the AADE15 meeting in New Orleans, LA.
- I was familiar with celiac disease among patients with type 1 diabetes, but did not know the statistics – 1-16% versus 0.3-1% in the general population, respectively.
- There has been change in desired A1C goals for the youth. Previous goals were: <8.5% for children younger than 6 years, <8% for children 6 to 12 years of age, and <7.5% for adolescents 13 to 19 years of age. In this position statement, the ADA recommended an A1C goal of <7.5% for all pediatric age groups.
- A growing area of research is beta-cell replacement therapy. On page 2047 of the position statement, recommendations of patient candidates for pancreas transplant and islet transplantation are provided.
- Pramlintide and some incretin agents have been studied as adjunctive therapy among patients with type 1 diabetes. While the studies have been small in sample size and short in length, the evidence is promising (i.e. reduction in A1C, reduction in total insulin dose, and promotion of weight loss). However, additional evidence is needed to have stronger conclusions and clinical application for patients with type 1 diabetes.
For more information, you can refer to the article: Chianga JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the American Diabetes Association, published in Diabetes Care on June 16, 2014 (DOI: 10.2337/dc14-1140).
A number of years ago I began to work in the hospital and was shocked at how many folks were in for foot wound debridement and amputations. Even though I have some patients in the outpatient world that have neuropathy and need medications to help them tolerate pain, and some who have lost a foot to an amputation, I was totally unprepared for the number of foot and below the knee amputations that were performed on a regular basis. And unfortunately, patients with excellent blood glucose management now, but poor control earlier in their lives with diabetes, were not immune.
Approximately 50% of patients with diabetes will develop neuropathy at some point in their lifetime, most experiencing peripheral neuropathy involving the lower extremities. Those with poor diabetes management are at highest risk.
As diabetes educators, it is important for us to include education about self-foot examinations in most of our education sessions. Visually inspecting feet should be done at most visits, with a thorough foot exam at least annually by a trained individual, be it a diabetes educator or medical provider. The annual exam should include visual examination of the feet as well as sensory assessment. In cases when problems are detected, referring to a podiatrist with a strong understanding of diabetes is a must. The new 3rd edition of The Art and Science of Diabetes Self-Management Education Desk Reference is a wonderful resource for providing information on frequency of screenings, explaining the visual foot assessment, and providing information on what should be included in a comprehensive foot exam.
In addition to screenings, prevention of complications starts with teaching patients to pay attention to their feet. Ask your patient if they wash their feet regularly? Dry between their toes? Take off their socks each night and check for any sores, dry or red areas. If the individual cannot see the bottoms of their feet, encourage the use of a mirror. Have a sample of one in your office and help them look at their feet. Remind them of the importance prompt medical attention if their assessment reveals any question about the health of their feet.
I can remember many years ago attending a session at an American Diabetes Association Annual Meeting, where the presenter showed slides of foot and leg complications of diabetes due to poor management. I was young and so surprised that something so destructive could be occurring, often undetected.
I am now no longer surprised, but saddened. Prevention is really the answer, and teaching patient to care and examine their feet, along with managing their blood glucose values, can go a long way to help reduce the risks of irreparable damage.
We as a nation have an obsession with food. Being in the diabetes arena brings it even more to the forefront as it has a significant impact on patients’ lives and glycemic control. It is a fine balance between eating properly, taking the correct medication for your food choices, and not feeling guilty if the choices were not exactly what the CDE had recommended. A major portion of each of our Diabetes Classes is spent discussing food choices – and it continues to be the part that patients find the most challenging.