Get Off the Couch and Work Your Core

plank-fitness-muscular-exercising-163437.jpegIf you suffer from diabetes, you already know that staying fit greatly benefits your health. Yet, many of the complications caused by diabetes can make it difficult to get the exercise you need; in fact, they can make a normal exercise routine difficult or even dangerous. For example, peripheral neuropathy (numbness in the feet caused by nerve damage) may affect your balance and put you at risk for a fall, or could lead to slow-healing ulcers that keep you inactive. On top of that, diabetes patients may have heart disease symptoms or vision problems that make getting up and going for a walk more risky than helpful.

The good news is that these complications don’t have to prevent you from doing safe and healthy exercise. You can still get a beneficial workout—minus the risks—by exercising your core. Even though a lot of people with diabetes think having neuropathy or other complications means they have to be a couch potato, that’s just not true. Just because you can’t get outside for a brisk walk or run doesn’t mean you can’t get fit. Exercising your core is a safe way to improve your strength and stability so you can better handle your daily life—right from your own home.

Core exercises are an important part of a well-rounded fitness program for diabetes patients. Your body core, including the muscles around your trunk, is particularly important to keep strong so you can go about your normal daily activity and prevent falls and injuries, particularly as you age. The best part? They are easy to do on your own in your home, and you don’t even need to purchase any equipment to perform them. However, once you become more advanced, you can accelerate your workouts using a gym ball or dumbbells.

Ready to get a strong core and improve your stability and overall wellness? Here are ten core exercises that I recommend highly for people with diabetes (or anyone for that matter).

Look for illustrated versions of these core exercises in Chapter 21 (“Ten Easy Exercises to Build a Strong Core without Leaving the House”) in Diabetes & Keeping Fit for Dummies by Dr. Sheri Colberg available online at or

(1) Abdominal Squeezes. This exercise is great for working your abdominals and getting your core as strong as possible. If you’re female and have gone through a pregnancy, getting these muscles in shape doing these squeezes is a must.

  1. Put one of your hands against your upper stomach and the other facing the other direction below your belly button.
  2. Inhale to expand your stomach.
  3. Exhale and try to pull your abdominal muscles halfway toward your spine. This is your starting position.
  4. Contract your abdominal muscles more deeply in toward your spine while counting to two.
  5. Return to the starting position from Step 3 for another count of two.

Work up to doing 100 repetitions per workout session.

(2) Plank or Modified Plank. Nobody likes doing planks, but they get the job done when it comes to boosting the strength of your core. Both planks and modified planks work multiple areas, including your abdominals, lower back, and shoulders.

  1. Start on the floor on your stomach and bend your elbows 90 degrees, resting your weight on your forearms.
  2. Place your elbows directly beneath your shoulders and form a straight line from your head to your feet.
  3. Hold this position as long as you can.

Repeat this exercise as many times as possible during each workout.

(3) Side Planks. A modification of regular planks, this side plank exercise works some of the same and some slightly different muscles that include your abdominals, oblique abdominal muscles, sides of hips, gluteals, and shoulders. Try doing some of both types for the best results.

  1. Put one of your hands against your upper stomach and the other facing the other direction below your belly button.
  2. Inhale to expand your stomach.
  3. Exhale and try to pull your abdominal muscles halfway toward your spine. This is your starting position.
  4. Contract your abdominal muscles more deeply in toward your spine while counting to two.
  5. Return to the starting position from Step 3 for another count of two.

Work up to doing 100 repetitions per workout session.

(4) Bridging. If you work on your abdominal strength, you also need to build the strength in your lower back to keep things balanced. Bridging is a good exercise to do that as it works your buttocks (including gluteals), low back, and hip extensors. Remember to breathe in and out throughout this exercise.

  1. Keeping your shoulders on the floor, slowly raise your buttocks from the floor with your stomach tight and your lower back straight.
  2. Gently lower your back to the ground.
  3. Repeat Steps 1 and 2.

(5) Pelvic Tilt. An easy exercise to do, the pelvic tilt works your lower back and lower part of your abdominals.

  1. Lie on your back on the floor with your knees bent and feet flat on the floor.
  2. Place your hands either by your sides or supporting your head.
  3. Tighten your bottom, forcing your lower back flat against the floor, and then relax.
  4. Repeat Steps 2 and 3 as many times as you can.

(6) Superhero Pose. Whether you want to leap tall building with a single bound or not, try doing this superhero pose exercise to get a stronger core. It works many areas, including your lower back, upper back, back of shoulders, and gluteals.

  1. Lie on your stomach with your arms straight out in front of your head on the floor.
  2. Rest your chin on the floor between your arms.
  3. Keeping your arms and legs straight, simultaneously lift your feet and your hands as high off the floor as you can. Aim for at least three inches.
  4. Hold that position (sort of a superhero flying position) for 10 seconds if possible, and then relax your arms and legs back onto the floor.

(7) Knee Push-Ups. Push-ups are hard to do if you haven’t built up the strength in your shoulders yet, so this knee version is an easier way to start for most people. This exercise works your chest, front of shoulders, and back of upper arms.

  1. Get on your hands and knees on the floor or a mat.
  2. Place your hands shoulder-width apart on the floor.
  3. Tighten your abdominal muscles to straighten your lower back and lower yourself down toward the floor as far as you can without touching.
  4. Push yourself back up until your arms are extended, but don’t lock your elbows.

(8) Suitcase Lift. This exercise is the proper way to lift items from the floor. Before you begin, place dumbbells or household items slightly forward and between your feet on the floor. You work the same muscles used in doing squats (lower back and lower body) with this activity.

  1. Stand in an upright position with your back and arms straight, with your hands in front of your abdomen.
  2. Bending only your knees, reach down to pick up the dumbbells.
  3. Grab the dumbbells or items in both hands and then push up with your legs and stand upright, keeping your back straight.

(9) Squats with Knee Squeezes. These squats are not your normal squats. They’re more like a combination of squatting and wall sitting with a twist. You work the front and back of thighs, inner thighs (adductors), hip flexors and extensors all with this one exercise.

  1. Stand with your back against the wall, with your feet aligned with your knees and straight out in front of you.
  2. Place a ball or pillow between your knees and hold it there with your legs.
  3. Inhale to expand your stomach and then exhale and contract your abdominal muscles.
  4. Bend your knees and lower yourself into a squat. To avoid injuring your knees, don’t bend them more than 90 degrees.
  5. Squeeze the ball with your thighs, drawing your stomach muscles more deeply toward your spine.
  6. Do as many squeezes as you can up to 20 and then return to the starting position.

(10) Lunges. Lunges are a common activity to work on the front and back of thighs, hip flexors and extensors, abdominals and lower back all with one exercise. Do them with proper form to avoid aggravating your knees, though.

  1. Keep your upper body straight, with your shoulders back and relaxed and chin up.
  2. Pick a point to stare at in front of you so you don’t keep looking down, and engage your core.
  3. Step forward with one leg, lowering your hips until both knees are bent at about a 90-degree angle. Make sure your front knee is directly above your ankle, not pushed out too far, and don’t let your back knee touch the floor.
  4. Focus on keeping your weight on your heels as you push back up to the starting position.

Even though diabetes sometimes presents tough fitness challenges, you can use these core-strengthening exercises to maintain fitness in spite of any mobility issues you’re facing right now. Whether you still active or sedentary, working your core is a safe and smart way to improve your balance, keep you as fit as possible, and elevate your overall quality of life.


New book on fitness and diabetes

My latest book, Diabetes & Keeping Fit for Dummies, was released this week, just in time to help you start the new year out right. It covers everything you need to know about getting or staying fit with diabetes or prediabetes. Even if you don’t have diabetes and want to improve your insulin action and prevent type 2 diabetes, this book is for you! Check it out today! Available on or

Are You Getting Enough “SPA” Time?

You’ve probably heard about the recent reports revealing just how dangerous it is to be sedentary. Simply sitting for too long at one time is now a recognized health hazard that everyone should be aware of. But if you suffer from diabetes or prediabetes, a sedentary lifestyle is particularly dangerous. Getting regular exercise and movement is one of the most important things you can do keep your blood glucose under control, maintain a healthy body weight, and reduce your risk of developing complications related to diabetes.

Unfortunately, most people naturally try to do as little physical activity as possible in their day to day lives. How many times have you driven to a store and then circled around the parking lot or waited a long time to find a spot close to the door rather than just parking farther away and walking? When you do that, you’re missing out on a great opportunity for spontaneous physical activity, or SPA.

Spontaneous physical activity or “SPA time” is exactly what it sounds like. It consists of taking a dozen extra steps here and there, which can add up to a lot of calories burned over the course of the day, week, and year. SPA can happen when you get a few more steps by parking farther away or when you stand up or walk around while talking on the phone instead of sitting down. Doing anything—even fidgeting—makes your metabolism work better compared to sitting continuously for long periods of time.

If you have diabetes, adding in more daily movement in any way possible is likely to benefit your life in countless ways. If you get and stay more active every day by doing more SPA, you undoubtedly enhance and maintain your overall health, vitality, and youthful vigor more effectively. Doing easier activities like standing or walking around—even if they don’t make you break a sweat—uses up calories and helps you keep your weight stable.

Here’s one important thing to keep in mind: you won’t get as fit from doing most SPA activities like these, and SPA time alone is not adequate to fulfill your exercise requirements. (You’ll likely need to do both more daily SPA and some cardio, resistance, or other exercise training to keep fit with diabetes or prediabetes. But when matched for number of calories burned, doing easy or moderate spontaneous activities for more total time during the day works as well for improving your blood glucose and your aerobic capacity as doing harder, planned exercise for less time does.

Easy activities like cleaning, washing dishes, grocery shopping, gardening, playing with your kids or grandkids, walking the dog, standing, or any other activity can help lower your blood glucose and keep you more fit and active. Keep reading to learn some easy ways to incorporate more SPA time into your day:

  • Pace or stand while talking on the phone instead of sitting.
  • Always take the stairs instead of the elevator or escalator.
  • Window shop at the nearest mall.
  • Wash your car by hand (and wax it, too).
  • Put on some music and dance.
  • Set up a basketball net in your driveway and shoot some hoops.
  • Walk to a nearby school when school is out of session and use its playground equipment.
  • Hide the remotes for the TV, stereo, and other devices so you have to get up to adjust the settings.
  • Walk in place, dance, move around, or even just stand up while watching TV—at least during the commercials.
  • Limit your TV and home computer use to no more than two hours per day. If you can’t get down to that little, try lowering your current at-home screen time by 30 minutes to start.

Remember, when it comes to better managing your diabetes, all movement counts. SPA time is an easy way to get moving every day, so be sure to keep it going strong as a manageable, and low-impact addition to your fitness routine. Have fun with it, be creative, and above all, enjoy becoming a healthier and more active you.

Musings on Reaching 50 Years with Diabetes

In a break from my usual postings, this one is a stream of consciousness diatribe on my person experiences. Please indulge my musings since I’m nearing the half-century mark of living (well) with type 1 diabetes.

I got diabetes back in the Dark Ages (1968) of its treatment. The only feedback I had on my blood glucose levels was testing my urine, which was several hours behind my actual levels and no reflection on my immediate levels. I never had a number to go with a bright orange (4+) reading of my urine–meaning that I was at the high end of the scale for glucose in my urine–but it did give me a lot of negative reinforcement. It told me that I was “bad” or “not in control” or an unlovable kid–or something along those lines. In other words, it was worthless and only made me feel bad about myself and my diabetes as I grew older. I was convinced that I was going to die from diabetes complications before graduating from high school.

Getting a blood glucose meter when I was in my early 20’s–after 18 years of diabetes without there being any to measure it–was both eye-opening and terrifying. I actually had to go through the emotional stages of dealing with a chronic disease. I realized that I had likely been running in the 200s most of the time (despite taking my insulin as prescribed and following a “diabetes diet”). No more head in the sand! I had diabetes for good and had to deal emotionally with having it. Getting it as young as I did (age of four) and then not having the tools to manage it had effectively allowed me to avoid all of that before.

Once I got a meter, I religiously kept a log of everything affecting me and my blood glucose–food, insulin dosing, exercise, stress, lack of sleep–until I had a handle on how my body reacted to almost everything. In fact, I wrote down everything for over 25 years! Doing that, along with getting a PhD in exercise physiology and teaching nutrition for 19 years at the college level, gave me a greater understanding of how complex our bodily systems are when it comes to keeping blood glucose levels at optimal levels using suboptimal methods (insulin delivery through the skin instead of from the pancreas being the worst barrier of them all). Many of these methodological shortcomings of managing type 1 diabetes are still in play today.

I look forward to meeting the milestone of living for half a century with type 1 diabetes soon and getting my 50-year medals from Joslin and Lilly for doing so. It’s an accomplishment that is worth bragging about–even though I’m fine with living with diabetes at this point in my life. It would be nice to have a cure, but I’m okay with it either way. I live life to the fullest and focus on the important things in life. Because diabetes is largely responsible for teaching me to do that, having it has really been more of a blessing than anything else.

Exercise to Lower Your Risk of Dying (Prematurely) with Type 1 Diabetes

Bob Stewart Jumping (crop)Much of the research on length of life for individuals living with type 1 diabetes is pessimist, which makes a new study released recently a breath of fresh air. Data were collected for the ongoing nationwide, multicenter, Finnish Diabetic Nephropathy (FinnDiane) Study that tracked the death rate of 2,639 study participants for an average of 11.4 ± 3.5 years (1).

In this study, participants’ leisure time physical activity was reported via a self-report questionnaire. Importantly, their physical activity and its intensity, duration, and frequency were examined related to dying from all causes and from cardiovascular events; some of these adults with type 1 diabetes already had diabetic kidney disease.

The researchers also looked at potentially confounding factors like sex, how long people had been diagnosed with type 1 diabetes and how old they were when they got it, as well as physical measures like their systolic blood pressure, triglycerides (blood fats), BMI (body mass index), and HbA1c (a measure of overall blood glucose control over two to three months).

The conclusions of this study came as no surprise to me: exercise is associated with a lower risk of premature death from cardiovascular or any other cause in adults with type 1 diabetes. Overall, 270 people died during the follow-up period, 127 of whom had kidney disease. Only exercise intensity was associated with cardiovascular mortality, with intense activity being best for preventing early death from cardiovascular events. Both how much total physical activity they got and how frequently they exercised were associated with a lower risk of dying from any cause. Prior studies have shown that exercise frequency may also matter in preventing such events, with a higher frequency of physical activity lowering the risk (2).

People with type 2 diabetes have already been shown to have a lower risk of premature death when they are physically active (3); this is also true for the adult population in general (4; 5). However, not as many studies have looked specifically at the association between physical activity and lower mortality risk in adults with type 1 diabetes. Type 1 diabetes has previously been associated with a shorter lifespan in many adults with it, particularly related to endothelial dysfunction and cardiovascular disease (6).

Earlier studies, such as the DCCT, have shown that keeping blood glucose levels in a more normal range can help lower the risk of diabetes-related complications in people with type 1 diabetes. Most deaths in this population are related to either cardiovascular events or kidney failure. Exercise has an innate ability to lower oxidative stress, which has been implicated in the development of many complications, as well as improve endothelial function (6). While regular physical activity is associated with a lower risk of early death in adults with and without type 2 diabetes, this study is one of the first to examine this association in type 1 diabetes.

While the exact amount of exercise needed to lower the risk of cardiovascular events is unknown and not determined by this study, doing any activity is arguably better than remaining sedentary. As in people without diabetes, intense activity likely is even more cardioprotective than moderate or light activity.

However, the exercise in this study was self-reported and only collected at the start of the study, making it is hard to draw definitive conclusions about how much exercise people need to do and how intense it needs to be to reduce the risk of dying.

In conclusion, as confirmed by this latest study, being physically active on a regular basis is critical to living long and well with type 1 diabetes. Remaining sedentary is far worse for your health and your longevity, so go get active!


References cited:

  1. Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Tikkanen HO, Groop PH: Physical Activity Reduces Risk of Premature Mortality in Patients With Type 1 Diabetes With and Without Kidney Disease. Diabetes Care 2017;16:dc17-0615
  2. Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Rosengard-Barlund M, Gordin D, Tikkanen HO, Groop PH: Frequent and intensive physical activity reduces risk of cardiovascular events in type 1 diabetes. Diabetologia 2017;60:574-580. doi: 510.1007/s00125-00016-04189-00128. Epub 02016 Dec 00124.
  3. Loprinzi PD, Sng E: The effects of objectively measured sedentary behavior on all-cause mortality in a national sample of adults with diabetes. Prev Med 2016;86:55-57
  4. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA: Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015;162:123-132
  5. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, Bauman AE, van der Ploeg HP: Daily sitting time and all-cause mortality: a meta-analysis. PLoS One 2013;8:e80000
  6. Bertoluci MC, Ce GV, da Silva AM, Wainstein MV, Boff W, Punales M: Endothelial dysfunction as a predictor of cardiovascular disease in type 1 diabetes. World J Diabetes 2015;6:679-692

Are My Joint Issues Due to Being Active, Normal Aging, or Diabetes?

Sheri DHHS 30th climbing side viewLiving with diabetes often leads me to wonder if what I’m experiencing—particularly when it’s an irritated joint or an overuse injury—is a consequence of being a regularly physically active person, getting older, or having diabetes, or some combination of those. Which one of these is causing my joint issues? Is it possible to know? I will attempt to answer these questions based on my deeper dive into the published research.

Personally, I have managed to avoid most overuse injuries (such as joint tendinitis) related to physical activity by engaging in cross-training and doing different activities on varying days, and this strategy worked well for me for over 25 years. Of late, though, I have started experiencing chronic overuse injuries (or sometimes just short-term joint irritation) that appear to arise not from most of my usual activities, but more from unusual ones—such as hand-scrubbing my house to get it ready to sell (dominant shoulder joint irritation), tamping down my front yard with a hand compactor (alternate shoulder joint pain that lasted for several years and recurs occasionally), driving a car for several hours in traffic after not driving far often (ankle joint tendinitis of some sort that took months to fully resolve), and random aches and pains in joints that come and go on any given day and may only last a few days at most.

Yes, I’m getting older (aren’t we all?), having successfully passed the half-century mark. I’ve also been living with type 1 diabetes for nearly 50 years (diagnosed at age four in 1968). My A1Cs are in recommended ranges (usually near 6.0%) and have been good ever since I got my first blood glucose meter in 1986 (after going 18 years with nothing but urine testing). I still have blood glucose fluctuations while trying to manage food, exercise, stress, occasional lack of sleep, hormonal variations, illness, and other usual factors that impact my daily levels. So, are my own occasional joint issues the result of being an active person (exercising daily for decades), normal aging, or long-standing diabetes (despite being in relatively good control for the past 30+ years)?

Are overuse injuries more likely to occur due to diabetes or aging? Overuse injuries from participation in athletic endeavors (even just walking) are more common in people with diabetes, likely due to changes in joint structures when exposed to hyperglycemia over time (1). But aging also increases the incidence of overuse injuries when exercisers are older (2). For instance, in one study 70% of the injuries in older exercisers (over 60 years) were overuse injuries, but accounted for only 41% of injuries in younger adults (early 20s).

Is it due to inflammation related to aging or to diabetes? Aging lab rats have overuse activity changes to the structure of their tendons related to inflammation that may make them more prone to injury (3), but when it comes to humans, the research is unclear whether inflammation is involved (4). In one review (5), “prolonged systemic, low-grade inflammation and impaired insulin sensitivity act as a risk factor for a failed healing response after an acute tendon insult and predispose to the development of chronic overuse tendinopathies.” Perhaps, then, in people with diabetes, joint structures do not respond as well to or repair as quickly after activities (6).

Others have argued that low-level, systemic inflammation is not involved in changes to tendons that may lead to injury (4). People with diabetes have some structural joint changes that may or may not be related to diabetes duration or type, although poorer blood glucose management has been associated with higher levels of systemic inflammation (1). Fit, active adults with type 1 diabetes with good blood glucose control exhibit more inflammatory markers in response to exercise, but appear to recover normally (7). If someone has had “good” control for many years, does that lower the chance that their overuse injuries are diabetes-related? I’m quickly raising more questions than I can answer!

Other joint issues like frozen shoulder, carpal tunnel syndrome, and trigger finger are more common in people with diabetes, and structural changes to tendons may occur in people with diabetes (8). On the other hand, my non-diabetic, aging (mid-50s), reasonably active neighbor has had two frozen shoulders in recent years that clearly have nothing to do with diabetes or blood glucose management. I’ve also known people with diabetes who are active that develop a frozen shoulder, but others who get this condition are sedentary, suggesting that such joint issues are not consistently related to diabetes or habitual physical activity.

In short, if you are reading this in hopes of finding out whether joint pains and overuse injuries are more related to being active, aging, or diabetes, you are about to be sorely disappointed because I am unable to determine that based on available research. That said, it is likely that getting older (and not springing back as quickly) contributes to the rise in overuse injuries with aging, but that just means that everyone will have to find ways to be active that do not aggravate any existing issues. The best policy still is to vary your activities, try not to overdo or act like you’re still twenty, and rest appropriately and take time off when necessary to recover from injuries. Given we’re all aging and a significant number of us will be developing diabetes in our later years (if we don’t have it already), it is a topic ripe with possibility for future research.


References cited:

  1. Abate M, Schiavone C, Salini V, Andia I: Management of limited joint mobility in diabetic patients. Diabetes Metab Syndr Obes 2013;6:197-207
  2. Kannus P, Niittymaki S, Jarvinen M, Lehto M: Sports injuries in elderly athletes: a three-year prospective, controlled study. Age Ageing 1989;18:263-270.
  3. Kietrys DM, Barr-Gillespie AE, Amin M, Wade CK, Popoff SN, Barbe MF: Aging contributes to inflammation in upper extremity tendons and declines in forelimb agility in a rat model of upper extremity overuse. PLoS One 2012;7:e46954. doi: 46910.41371/journal.pone.0046954.
  4. Kjaer M, Bayer ML, Eliasson P, Heinemeier KM: What is the impact of inflammation on the critical interplay between mechanical signaling and biochemical changes in tendon matrix? 1985) 2013;115:879-883. doi: 810.1152/japplphysiol.00120.02013.
  5. Del Buono A, Battery L, Denaro V, Maccauro G, Maffulli N: Tendinopathy and inflammation: some truths. Int J Immunopathol Pharmacol 2011;24:45-50.
  6. Battery L, Maffulli N: Inflammation in overuse tendon injuries. Sports Med Arthrosc 2011;19:213-217. doi: 210.1097/JSA.1090b1013e31820e31826a31892.
  7. West DJ, Campbell MD, Gonzalez JT, Walker M, Stevenson EJ, Ahmed FW, Wijaya S, Shaw JA, Weaver JU: The inflammation, vascular repair and injury responses to exercise in fit males with and without Type 1 diabetes: an observational study. Cardiovasc Diabetol 2015;14:71
  8. de Jonge S, Rozenberg R, Vieyra B, Stam HJ, Aanstoot HJ, Weinans H, van Schie HT, Praet SF: Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study. Br J Sports Med 2015;49:995-999. doi: 910.1136/bjsports-2014-093696.

What Do We Really Know about Exercising with Complications?

Back injury

As a clinical exercise researcher, I frequently have found it difficult to study exercise effects in people with health complications, even though this is critical information to know in order to make appropriate exercise guidelines. Try convincing your university Institutional Research Board, or IRB, that it is advisable to exercise people with eye issues like unstable proliferative retinopathy to find out if breath-holding, jumping, jarring, or head-down activities cause them to experience retinal hemorrhages. Understandably, that is not going to happen, nor should it.

In some cases, I have not even been allowed to study relevant populations—like when we wanted to study older adults with type 2 diabetes and balance or gait issues related to peripheral neuropathy. Our IRB required so many exclusionary criteria that we were only able to recruit healthy, older subjects with diabetes, not the ones for whom an exercise training intervention to improve balance would be most relevant (i.e., those with actual balance issues).

It is still worth revisiting the latest recommendations for exercising safely and effectively with a variety of diabetes-related health complications. Most of these are derived from clinical observations and practical experience rather than clinical studies, though. The table that follows is a compilation of all these recommendations. (Please access the entire ADA Position Statement online, including redacted references, at

Table 5: Physical activity consideration, precautions, and recommended activities for exercising with health-related complications (Modified from (1))

Health Complication Exercise Considerations Physical Activity Recommendations/Precautions
Cardiovascular Diseases
Coronary Artery Disease (heart disease) Coronary perfusion may actually be enhanced during higher intensity aerobic or resistance exercise All activities okay; consider exercising in a supervised cardiac rehabilitation program, at least initially
Exertional Angina (chest pain on exertion) Onset of chest pain on exertion, but exercise-induced ischemia may be silent in some with diabetes All activities okay, but heart rate should be kept 10 or more beats/min below onset of exercise-related angina
Hypertension (high blood pressure) Both aerobic and resistance training may lower resting blood pressure and should be encouraged; some blood pressure medications can cause exercise-related hypotension Ensure adequate hydration during exercise; avoid Valsalva maneuver during resistance training
Myocardial Infarction (heart attack) Stop exercise immediately should symptoms of myocardial infarction (such as chest pain, radiating pain, shortness of breath, and others) occur during physical activity and seek medical attention. Restart exercise post-MI in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Stroke Diabetes increases the risk of ischemic stroke; stop exercise immediately if symptoms of a stroke (occurring suddenly and often affecting only one side of the body) during exercise Restart exercise post-stroke in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Congestive Heart Failure Most common cause is coronary artery disease and frequently follows a myocardial infarction Avoid activities that cause an excessive rise in heart rate; focus more on doing low- or moderate-intensity activities
Peripheral Artery Disease Lower-extremity resistance training improves functional performance Low- or moderate-intensity walking, arm ergometer, and leg ergometer preferred as aerobic activities; all other activities okay
Nerve Disease
Peripheral Neuropathy Regular aerobic exercise may also prevent the onset or delay the progression of peripheral neuropathy in both type 1 and type 2 diabetes Proper care of the feet is needed to prevent foot ulcers and lower the risk of amputation; keep feet dry; use appropriate footwear, silica gel or air midsoles, and polyester or blend socks (not pure cotton); consider inclusion of more non-weight-bearing activities, particularly if gait altered
Local Foot Deformity Manage with appropriate footwear and choice of activities to reduce plantar pressure and ulcer risk Focus more on non-weight-bearing activities to reduce undue plantar pressures; examine feet daily to detect and treat blisters, sores, or ulcers early
Foot Ulcers/Amputations Moderate walking is not likely to increase risk of foot ulcers or re-ulceration with peripheral neuropathy Weight-bearing activity should be avoided with unhealed ulcers; examine feet daily to detect and treat blisters, sores, or ulcers early; amputation sites should be properly cared for daily; avoid jogging
Autonomic Neuropathy (central nerve damage) May cause postural hypotension, chronotropic incompetence, delayed gastric emptying, altered thermoregulation, and dehydration during exercise; exercise-related hypoglycemia may be harder to treat in those with gastroparesis With postural hypotension, avoid activities with rapid postural or directional changes to avoid fainting or falling. Those with cardiac autonomic neuropathy should have physician approval and possibly undergo symptom-limited exercise testing before commencing exercise. With blunted heart rate response, use heart rate reserve and ratings of perceived exertion (RPE) to monitor exercise intensity. With autonomic neuropathy, avoid exercise in hot environments and hydrate well.
Eye Diseases
Mild to Moderate Nonproliferative Retinopathy Individuals with mild to moderate nonproliferative changes have limited or no risk for eye damage from physical activity All activities okay with mild, but annual eye exam should be performed to monitor progression. With moderate non-proliferative retinopathy, avoid activities that dramatically elevate blood pressure, such as powerlifting
Severe Nonproliferative and Unstable Proliferative Retinopathy Individuals with unstable diabetic retinopathy are at risk for vitreous hemorrhage and retinal detachment Avoid activities that dramatically elevate blood pressure, such as vigorous activity of any type. Also avoid vigorous exercise, jumping, jarring, and head-down activities, and breath-holding. No exercise should be undertaken during a vitreous hemorrhage
Cataracts Cataracts do not impact the ability to exercise, only the safety of doing so due to loss of visual acuity Avoid activities that are more dangerous due to limited vision, such as outdoor cycling; consider supervision for certain activities
Kidney Disease
Microalbuminuria (micro bits of protein in urine) Exercise does not accelerate progression of kidney disease even though protein excretion acutely increases afterward. Greater participation in moderate-to-vigorous leisure time activity and higher physical activity levels may actually moderate the initiation and progression of diabetic nephropathy All activities okay, but vigorous exercise should be avoided the day before urine protein tests are performed to prevent false positive readings
Overt Nephropathy (protein in urine) Both aerobic and resistance training improve physical function and quality of life in individuals with kidney disease; individuals should be encouraged to be active All activities okay, but exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced
End-Stage Renal Disease (needing dialysis and/or kidney transplant) Doing supervised, moderate aerobic PA undertaken during dialysis sessions may be beneficial and increase compliance


Exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced; electrolytes should be monitored when activity done during dialysis sessions
Orthopedic Limitations
Structural Changes to Joints More prone to structural changes to joints that can limit movement, including shoulder adhesive capsulitis, carpal tunnel syndrome, metatarsal fractures, and neuropathy-related joint disorders (Charcot foot)


In addition to engaging in other activities (as able), do regular flexibility training to maintain greater joint range of motion; stretch within warm-ups or after an activity to increase joint range of motion best; strengthen muscles around affected joints with resistance training; avoid activities that increase plantar pressures with Charcot foot changes
Arthritis Common in lower extremity joints, particularly in older adults who are overweight or obese; participation in regular physical activity is possible and should be encouraged; moderate activity may improve joint symptoms and alleviate pain Most low- and moderate-intensity activities okay, but more non-weight-bearing or low- impact exercise may be undertaken to reduce stress on joints; do range of motion activities and light resistance exercise to increase strength of muscles surrounding affected joints; avoid activities with high risk of joint trauma, such as contact sports and ones with rapid directional changes


Reference cited:

  1. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF: Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2065-2079.