Dr. S.M.Sadikot.
Hon. Endocrinologist,
Jaslok Hospital and Research Centre,
Mumbai 400026

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 long term 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!

Diet and exercise are the mainstay of good diabetes management. In fact, many patients can be controlled quite adequately with the use of diet and exercise alone. In pointing out the importance of exercise, one is not saying anything new. More than 2,000 yrs. ago, Sushruta advocated the use of exercise in the management of diabetes! Unfortunately, with the advent of insulin and oral agents, the role played by exercise went into an eclipse from which it is only now emerging. After all, if the patient can be controlled with the use of insulin or an oral agent, why make the patient exercise? Today, the picture seems to have changed radically and exercise has again come center stage.

A regular program of exercise not only helps in correcting many of metabolic abnormalities associated with diabetes, but also makes the person a much more fitter and healthier person. Exercise decreases the blood glucose levels (and it does this even without any change in the weight of the patient), it leads to an increase in insulin sensitivity, decreases the levels of triglycerides and the LDL-cholesterol, whilst increasing the HDL-cholesterol values. The energy spent during the exercise also contributes to the weight reduction of an overweight patient. I do not intend to discuss the beneficial effects of exercise in any further detail, but would rather focus on an aspect which I feel is quite neglected. This is the actual method of exercising. In other words, not so much the why as the what, how, when and where! Unfortunately, many who do understand the importance of exercise in diabetes management, do not really know the actual method by which an exercise program should be prescribed. Often, we just tell patients that they should exercise and patients accept this advice!

Today, if a patient came to a doctor with some infection, no doctor would say "Take antibiotics! ". Neither would any patient be satisfied with such advice. The doctor would need to prescribe the precise antibiotic that the patient would need to take. The patient would also be told the strength of the tablets, the number of times in the day that the tablets have to be taken, the time of taking these tablets, the relationship to meals, and the number of days that the course of antibiotics would have to be taken, and even the side effects which may be seen!

Yet many of us tell our patients that they must exercise and the patients accept this! 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. They should be evaluated for fitness to exercise and then given a detailed prescription of the type of exercise, the intensity of the exercise, the timing and the duration of the exercise schedule. The patient must also be advised about any special aspects, precautions and side effects associated with the exercise regime. These are the areas that I would like to discuss in some detail.

EVALUATION

Before the actual prescription of the exercise schedule, every patient should be evaluated regarding fitness to undertake the exercise programme. Theoretically, this would mean that all the patients would need to undergo a cardiac stress test, but this is obviously not feasible on such a large scale and frankly, not really necessary. In my opinion, a good history and clinical examination along with a few routine investigations would show us the patients who may be at an extra risk whilst undergoing an exercise program. If a patient has a significant degree of ischemic heart disease, they would do better to follow a special cardiac program. Patients with proliferative retinopathy should avoid vigorous exercise at least until they 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 anesthesia and peripheral vascular disease would require special attention. But the vast majority of diabetics can well follow an exercise schedule and should be made to do so!

The following questionnaire has been shown to be very useful to assess the fitness of the patient before carrying out any exercise program.

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 a patient responds positively to any of these questions, it may be worthwhile to assess that patient more thoroughly. Moreover, the patient can be given this questiuonnaire to keep and if the response for any of the questions changes from a negative to a positive, the patient should be asked to contact the doctor as soon as possible.

It is needless to say that all diabetics who are put on an exercise program should be closely monitored at least in the initial stages. I would also like to point out that this initial evaluation does not entail any extra cost to the patient as this is a routine part of any good initial evaluation for every patient with diabetes!

THE TYPE OF EXERCISE

Once the patient is found fit to undertake the exercises, the first and possibly the most important, step in the prescription of exercise is to choose the type of exercise. The exercise schedule would need to be followed for many a year and therefore, the exercise chosen should be individualised for every patient. Consideration must be given to the needs, work schedule, hobbies, interests, skills, ability and also, quite importantly, to the financial capacity! In other words, the type of exercise that the patient chooses should be one that one would be able to carry out easily, regularly and for a long period.

Most patients need and should be prescribed, isotonic exercise. These involve movements and use of the large muscles of the body. Isometric or muscle tensing exercises like weight lifting, Bullworker and pushups are not suitable for most of the patients and should be reserved for the very young patients and athletes with a special interest in developing certain muscles. These isometric exercises are specially meant to develop muscles and stamina, but they also cause a significant rise in the blood pressure and this can be very dangerous for many patients especially if they already have retinal and renal complications or have hypertension. These exercises are not easy to carry out on a regular basis. Isotonic exercises are definitely more safer, easier and more than sufficient to meet the needs of most patients.

It is important to take into consideration the work schedule of the patient when planning the type of exercise. A patient holding a nine to five job obviously cannot plan to play games or go swimming every afternoon. The patient must also have easy access to, or an opportunity to undertake the exercise that is chosen. Tennis, swimming, badminton, etc, are all excellent forms of isotonic exercises but one must consider whether the patient would be able to regularly carry out these forms of exercise! Does one have a regular and easy access to a swimming pool or a tennis court? This often means that one should belong to some club or hotel. These are not only quite difficult to come by, but are also quite expensive. Add to this, the cost of playing some games like tennis! Thus, one would not only have to consider if the patient would have an opportunity to carry out the exercise schedule regularly, but also if one would able to bear the financial burden of this exercise schedule! The skills and ability of the patient should also be considered. To give an extreme example, the patient cannot be allowed to choose hill climbing as the form of exercise, when one finds it difficult to climb up one or two floors. It is also important to realise that the type of exercise chosen should be of interest to the patient. The patients will need to do this exercise for a long time and one cannot get "bored" with the exercise. One way out of this dilemma would be to choose different forms of exercise so that the type of exercise could be varied. But when patients are given too many choices, I find that they end up doing none!

One may feel from the above discussion that what I am saying seems to be very obvious to most people, but from my experience I know that unless we help the patient in choosing the type of exercise, most of them have an inherent tendency to choose the most exotic and fancy forms of exercise which they have no hope of carrying out for any period of time, thus defeating the very purpose of an exercise program. Let us take an example from clinical experience. All of a sudden one finds that when we ask many of our patients, especially the younger ones, about the type of exercise that they would like to undertake, quite a few of them choose to play tennis. This usually occurs in the month of July. A closer analysis would show that this is after the massive coverage given to the Wimbledon Championships on TV. I usually discourage all these sudden flights of fancy as these have a tendency to be quite short lived, even if they ever take off in the first place.

It should be clear from this discussion that choosing the type of exercise requires careful consideration, taking into account all the various factors that have been referred to. I do not leave the choice entirely to the patient, but discuss the various options before him and then jointly reach a consensus about the type of exercise to be carried out.

Personally, I am in favour of walking as the type of exercise best suited for most patients. Walking needs no learning or special skills; after all, everyone can walk! Walking can be done easily, regularly, anywhere and anytime, needs no special equipment, clothes or place, is relatively the safest and costs nothing.