Consultant in Endocrinology, Diabetes and Metabolic Disorders,
Jaslok Hospital and Research Centre, Mumbai.

When your doctor tells you to exercise, he is saying nothing new. More than 2000 years back, Charak, in his Charak Samhita advocated the use of exercise in treating diabetes. In fact, the use of exercise in the treatment of diabetes was prescribed as early as 600 BC by the Indian physician Sushruta, and was widely recommended by physicians of the 18th century. Elliott Joslin, often called the Father of modern diabetes, identified exercise along with dietary management and insulin administration as one of the three components of good therapy in the 1920's.

It could be argued that in the absence of any other forms of treatment, the older day physicians had no choice but to fall back on diet and exercise! Later, with the wide availability of oral hypoglycemic agents and insulin, the relative importance of exercise as a treatment for diabetes seemed to go into a decline from which it is just emerging.

With the longterm safety and efficacy of some of the oral agents being called into question and with reports that ill advised insulin therapy leading to high blood insulin levels can be a factor in leading to many disorders such as high blood pressure, lipid disorders and even atherosclerosis, attention is being again given to diet and exercise as the dominant treatment modalities, as far as possible.

If a diabetic can be managed with the use of diet and exercise alone, or if the addition of exercise can lead to a substantial decrease in the dose of the oral agent or the insulin, can there be any justification for not prescribing exercise to the diabetic!

It is well documented that for every mile that you jog, you add one minute to your life. This enables you, at age 85, to spend an additional 5 months in a hospital at Rs.50,000 per month

EXERCISE.......WHY?

But who likes to exercise, and too regularly. In the modern age where even the routine activity in daily life has been decreased due to the availability of modern gadgets and conveniences, exercise for many is the use of one's thumb to press the "Remote Control" button!

But..........

My grand mother started walking 5 miles a day when she was 60 . She is now 97 and I dont know where the hell is she.

But how does one go about exercising? Patients are often told that they must exercise! And many of us accept this. Today, if you went to a doctor with an infection, and were told "Take antibiotics! ", would you accept this? Frankly, no doctor would give such advise. The doctor would need to prescribe the precise antibiotic that the you would need to take. You would also be told the strength of the tablets, the number of times you have to take the tablets daily, the number of days that the tablets need to be taken, the time of taking the tablets, the relationship with mealtimes and even the side effects that the patient may experience!

But when it comes to exercise, patients are told to exercise and they accept this advise. Such simple instructions may mean different things to different patients and from a therapeutic viewpoint are absolutely useless. Just as a prescription is written for any drug that the patient needs to take, it is essential that a detailed prescription of the exercise schedule be made for every patient. You should be evaluated for fitness to exercise and then there should be a discussion of the type of exercise, the intensity of the exercise, the timing and the duration of the exercise schedule.

It is also essential that you be advised about any special aspects, precautions and side effects associated with his exercise regime.

I joined the health club last year, spent around Rs 40,000/. Havent lost a pound. Apparently you have to show up.

EXERCISE........EVALUATION

Before undertaking an exercise schedule, you will need to be evaluated for your fitness to exercise.

In my opinion, a good history and clinical examination along with a few routine investigations would tell the doctor if you are at special risk to undertake an exercise programme.

If you have a significant degree of ischemic heart disease, it may be better for you to follow a special cardiac program for exercise. In case you have been told that you have eye complications such as proliferative retinopthy, then you should avoid vigorous exercise atleast until you have been adequately managed by laser therapy. Similarly those with a significant degree of kidney involvement would also do well to avoid any sudden and vigorous activity. The feet of the patients, especially those with a severe degree of anaesthesia and peripheral vascular disease would require special attention. But the vast majority of people with diabetes can well follow an exercise schedule and should be made to do so!

It is needless to say that all diabetics who are put on an exercise programme should be closely monitored atleast in the initial stages.

I would also like to point out that this initial evaluation does not entail any extra cost to you as this is a routine part of any good initial evaluation for every diabetic patient!

Should all patients have a cardiac stress test before they undertake an exercise schedule?

An exercise stress test may also be helpful to assess the cardiovascular system if an exercise program of moderate-to-high intensity is to be undertaken and there is high risk for underlying heart disease. It may be better to have a graded stress test if one of the following criteria is present:

• age > 35 years

• type 2 diabetes of > 10 years' duration

• type 1 diabetes of > 15 years' duration

• presence of any additional risk factor for coronary artery disease (smoking, high cholesterol, high blood pressure, obesity, stress)

• presence of microvascular disease (retinopathy, nephropathy, microalbuminuria)

• peripheral vascular disease

• autonomic neuropathy

I have to exercise early in the morning before my brain figures out what I am doing.

Here is a General Checklist which can help you judge your fitness to exercise.

Modified Physical Activity Readiness Questionnaire (PAR-Q) Regular exercise associated with many health benefits, yet any change of activity may increase the risk of injury. Completion of this questionnaire is a first step when planning to increase the amount of physical activity in your life. Please read each question carefully and answer every question honestly:

Yes	No	1) Has a physician ever said you have a heart condition and you should only do physical activity recommended by a physician?
Yes	No	2) When you do physical activity, do you feel pain in your chest?
Yes	No	3) When you were not doing physical activity, have you had chest pain in the past month ?
Yes	No	4) Do you ever lose consciousness or do you lose your balance because of dizziness?
Yes	No	5) Do you have a joint or bone problem that may be made worse by a change in your physical activity?
Yes	No	6) Is a physician currently prescribing medications for your blood pressure or heart condition?
Yes	No	7) Are you pregnant?
Yes	No	8) Do you have insulin dependent diabetes?
Yes	No	9) Are you 55 years of age or older?
Yes	No	10) Do you know of any other reason you should not exercise or increase your physical activity?

If you answered yes to any of the above questions, talk with your doctor by BEFORE you become more physically active. Tell your doctor your intent to exercise and to which questions you answer yes.

If your health changes so you then answer yes to any of the above questions, seek guidance from a physician.

This Checklist is only for general guidance and it would be better for you to discuss your schedule with your doctor before starting on the exercise program.

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