Preexercise Consultation and Exam

You need to consult your physician before you start an exercise program. If you have type 1 diabetes, your risks associated with exercise are higher than they are for someone with type 2. In addition, those with type 1 diabetes are usually at or below their ideal body weight. So if you have type 1 diabetes, you should look at exercising as a means of improving your overall health rather than losing weight. For example, if you have type 1 diabetes and you have high cholesterol, you can improve your cholesterol with exercise regardless of your body composition (Laaksonen et al. 2000). If you have type 2 diabetes, achieving and maintaining a healthy weight will be most important in thriving with diabetes.

If you've been diagnosed with diabetes but you have not experienced any noticeable symptoms, you should still visit with your physician to review your health risks. Those with diabetes have an average of three times the risk of having high cholesterol and triglycerides than those without diabetes. This is also referred to as dyslipidemia, a condition in which the blood levels of "bad" cholesterol (LDL or low-density lipids) and triglycerides are too high and levels of “good” cholesterol (HDL or high-density lipids) are too low. This diagnosis alone can increase your risk of heart problems and should be addressed by your health care provider.

Unfortunately, many patients diagnosed with diabetes are not counseled on the benefits of exercise. In fact, one study (Wee et al. 1999) published in the Journal of the American Medical Association shows that only 34 percent of physicians counsel their patients about exercise. In today's medical environment of managed care, it has become more difficult for physicians to spend time counseling their patients on exercise. Many patients are turning to nurses who specialize in diabetes education, which is important to your overall care.

The American Diabetes Association has developed an easy way to remember three main targets to strive for to prevent complications, mainly heart disease. These targets are known as the ABCs (see table 4.2). The letter A represents A1C, or hemoglobin A1C, which is a measure of your average glucose level over the last three months. The ideal level is less than 7 percent and should be evaluated at least twice per year. The B is for blood pressure, which should be checked at each visit with a physician or nurse, and it should be less than 130/80 mmHg. The letter C is for cholesterol, specifically LDL (bad cholesterol). Your LDL should be monitored at least once a year and ideally will be less than 100 mg/dl.

Table 4.2 The American Diabetes Association ABCs

At your preexercise consultation and exam, your physician will determine whether you have conditions and risks (diabetes-related or not) that can interfere with your exercise program. Certain screenings should be done in those with diabetes and in all people in certain age groups. Besides the main risk of cardiovascular disease, there are other risks that your physician must determine. The following list summarizes these risks so that you can be aware of what to expect during the visit with your doctor.

• Peripheral Vascular Disease. The symptoms include pain in the legs while walking (known as intermittent claudication), hair loss, cold feet, decreased pulse rate, and thinning of the tissues in the extremities. By restricting blood flow to the extremities, peripheral vascular disease can hinder proper muscle function. See chapter 2 to review specifics about peripheral vascular disease.

• Peripheral Neuropathy. Symptoms include decreased sensation and burning sensation in the extremities, especially the feet. More extreme symptoms such as numbness or pain in the limbs or decreased control of the muscles or the bowels or bladder can also signal problems with peripheral nerve function. See chapter 2 and the section called "Risks of Exercising With Diabetes” in this chapter to review specifics about peripheral neuropathy.

• Eye Disease. Visual difficulties of any kind including symptoms such as blurred vision should be taken seriously. As discussed in chapter 2, all people with type 1 diabetes should have annual eye exams, and all people with type 2 diabetes should receive an eye exam by an ophthalmologist at the onset of their diagnosis.

• Autonomic Neuropathy. The main symptoms of autonomic neuropathy as it relates to exercise include heat intolerance, the inability to sense hypoglycemia, and difficulty maintaining appropriate heart rate and blood pressure. If you have problems maintaining an appropriate heart rate or blood pressure, which often result in light-headedness or fainting, your doctor will order specific tests to see whether you have this condition. These tests can be as simple as taking your blood pressure in various positions such as lying, sitting, and standing and then comparing the results. Other tests, such as the tilt table test, may be more complicated. This test monitors your heart rate and the heart's electrical activity, blood pressure, and symptoms while you've in various positions on a machine called a tilt table. See chapter 2 for a review of autonomic neuropathy.

• Other Conditions. Other conditions that do not directly relate to diabetes but should be addressed at your preexercise exam are asthma (including exercise-induced asthma), anemia (decreased ability to carry oxygen and blood), and heat-related conditions (ranging from milder problems such as heat stress to severe problems such as heat stroke that results from the body's loss of the ability to regulate temperature). You should also discuss with your physician any problems that you have found that affect you when you exercise.