Category Archives: Exercise Precautions

When Do You Need a Checkup First Before Starting Exercise?

BP checkHow do you know if you need to get a checkup or medical clearance before you start any exercise training? You should have regular checkups at least annually with your doctor or another healthcare provider if you have any type of diabetes. This helps you keep on top of any problems that may pop up over time that have nothing to do with being physically active.

However, you probably don’t need to see a doctor before you start doing easy workouts or moderate activities like brisk walking. Requiring anyone with diabetes to get medical clearance before starting any type or intensity of exercise is recommended by the American College of Sports Medicine, but is not recommended by the American Diabetes Association because it sets too big of a barrier to participating in regular activities.

On the other hand, having a checkup before you begin more vigorous workouts is a good idea. It also depends on your age, your general health, and your physical activity level. If you’re already doing intense exercise, it’s not necessary, but it is advised for almost everyone with diabetes who is not already exercising at that level—just to be safe.

If/when you do have a checkup, get your blood pressure, heart rate, and body weight measured. If your doctor recommends that you do an exercise stress test, you’ll have to do walking on a treadmill or riding a stationary bike for around ten minutes. Your checkup may also include lab tests (urinalysis, kidney function testing, serum lipid evaluation, and electrolyte analysis) and screening for any diabetes-related complications (including heart, nerve, eye, and kidney disease). Most complications will not keep you from being active, but you may need to take precautions to exercise safely and effectively in certain cases.

For most people, getting a diagnostic graded exercise test is really going too far. Having one is only recommended by the American Diabetes Association if you’re over 40 and have diabetes; or if you’re over 30, have had diabetes for 10 or more years, smoke, have high blood pressure, have high cholesterol, or have eye or kidney problems related to diabetes. If you’re planning to do vigorous training that gets your heart rate up high, these criteria are relevant. If you’re just planning on doing mild or moderate aerobic activity or resistance training, such extensive (and often expensive) testing is unnecessary if you’re reasonably healthy or already fit and don’t have any symptoms of heart or vessel disease.

If you have any pre-existing health complications, you may need to take extra care to prevent problems during exercise. If your blood glucose has been in check, you’ve already been physically active, and you don’t have any serious diabetic complications, then go ahead and keep doing what you’re doing. If you’re very active, getting an extra checkup before you replace your current exercise regime with another exercise routine is neither necessary nor advised.

You still may need to take certain precautions when you exercise, particularly related to getting low blood glucose during and following the activity, going too high, and getting dehydrated. If you have any concerns, check with your healthcare provider at your next visit to discuss any precautions that may be important for your unique health circumstances when exercising.

Being Active and Getting Injured: How to Prevent This Conundrum

Back injury

You finally decide to get active to help manage your type 1 or type 2 diabetes better or to prevent type 2 altogether, and once you’ve hit your stride, you get an injury that puts you back on the couch! Getting injured from being active happens often enough that you need to know how to prevent and treat injuries so you can stay on track. The best medicine is prevention, so trying to prevent injuries before they happen is the best way to avoid having to take time off from exercising and sidetracking your fitness program. Here are some things you need to know:

The incidence of activity-related injuries, such as inflamed tendons (tendinitis) and stress fractures in bones, rises dramatically when people do more than 60 to 90 minutes of moderate or hard exercise daily. These types of overuse injury are nagging and persistently uncomfortable. Overuse injuries occur following excessive use the same joints and muscle in a similar way over an extended period of weeks or months. If you develop an overuse injury, it’s likely to be the result of excessive training, or doing too much too soon. In my own experience (since I’ve been regularly active for decades), they can also arise from doing something unusual, such as putting down a paver driveway, beating the yard into submission, or cleaning excessively prior to putting the house on the market.

Overuse injuries are more common in anyone with diabetes because elevated blood glucose can affect the health of your joints. Although everyone gets stiffer with age, diabetes accelerates the usual loss of flexibility especially when blood glucose is higher. Glucose “sticking” to joint surfaces makes people with diabetes more prone to overuse injuries like tendinitis and frozen shoulder (1; 2). It may also take longer for joint injuries to heal properly. The bones themselves can be thinned by exposure to elevated blood glucose levels, making fractures more common in people with any type of diabetes (3). The best prevention of any of these issues is optimal blood glucose control and regular stretching to maintain motion around joints.

You’ll likely benefit from doing a variety of activities on a weekly basis, an approach known as cross-training. Changing up your workouts is really they key to avoiding overuse injuries, keeping exercise fresh and fun, and getting more fit. Each activity a person does stresses muscles and joints differently, which lowers the risk of injury. It adds variety to an exercise program when you include activities like walking, cycling, rowing, swimming, arm biking, weight training, aerobic classes, and yoga, and it gives you the flexibility to choose different options based on your time constraints, the weather, and other factors. It also allows you to rest some muscles and joints without stopping exercising entirely. Alternating hard and easy days to lower the constant stress on muscles and joints is also a great idea.

To prevent overuse injuries, progress your exercise slowly (particularly the intensity), choose safe activities for you personally, always warm up and cool down, and make sure that you stretch your muscles regularly to stay more limber. For ongoing problems, treat affected areas with R.I.C.E. (rest, ice, compression, and elevation), combined with anti-inflammatory medications like ibuprofen (Advil or Nuprin) or naproxen sodium (found in Aleve), and avoid going back to normal activities or aggravating joints further until your symptoms resolve.

Finally, taking at least one day a week off from planned activities to rest allows your body time to recuperate and may prevent overuse injuries like tendinitis and stress fractures. It doesn’t mean that you have to stop moving, though, so keep your bodies in motion even on your days off for optimal blood glucose control.

References cited:

1. Abate M, Schiavone C, Pelotti P, Salini V: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2011;23:997-1003

2. Ranger TA, Wong AM, Cook JL, Gaida JE: Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med 2015;

3. McCabe L, Zhang J, Raehtz S: Understanding the skeletal pathology of type 1 and 2 diabetes mellitus. Crit Rev Eukaryot Gene Expr 2011;21:187-206

Better Dehydrated than Overhydrated during Exercise

Jen Alexander (T1D)An updated position statement on the dangers of hyponatremia (also known as water intoxication) was just released (1). It once again highlights how drinking too much water or any fluids during physical activity in the hopes of preventing dehydration can be potentially fatal.

Taking in too much fluid dilutes the sodium levels in your blood, and severely low sodium levels can lead to brain swelling, seizures, coma, and death. Less severe, symptoms of hyponatremia include nausea and vomiting, headache, confusion, loss of energy and fatigue, restlessness and irritability, and muscle weakness, spasms or cramps.

Hyponatremia has become a problem in recent years following the push to stay hydrated during all exercise, but until recently has primarily been associated with marathon races and other prolonged endurance events, especially among slow participants. Their main problem is that they don’t sweat that much, but they drink at every opportunity, often to excess over many hours due to fear of getting dehydrated. More recently, though it has been reported as being a problem during half-marathons, sprint triathlons, long hikes, yoga classes, and team sport practices and games, particularly football at all levels.

Drinking sports drinks or other fluids with electrolytes in them instead of straight water can help a little bit, but hyponatremia appears to be more related to your total fluid intake, not whether or not the drinks contain some sodium in them (2). Sports drinks containing added sodium are still more dilute than what’s in your blood, and drinking any fluids in excess during exercise can lower your blood sodium levels.

This condition is almost completely preventable. The key is simply to drink only when you feel thirsty during exercise. It really isn’t necessary to stay ahead of your thirst. The small impact that slight dehydration is going to have on your performance is nothing compared to the medical emergency created by drinking too much. Listening to your “innate thirst mechanism” provides a safe and reliable guide to hydration (1).

Using thirst as your guide should not increase your risk for cramping either since dehydration may only contribute minimally to cramps, which are likely more associated with fatigue than dehydration/electrolyte losses (3). Even becoming severely dehydrated during exercise in the heat is not likely to cause muscle cramps (4).

Surprisingly, becoming dehydrated during exercise will not necessarily increase the risk of developing a heat-related illness like heat stroke either. A body mass loss of up to 3% (mostly fluid losses through sweating) was found to be tolerated by well-trained triathletes during an Ironman competition in warm conditions without any evidence of heat illnesses (5). In fact, athletes who collapse from heat illness often are quite well-hydrated, and it’s more likely that cramping and heat illnesses come from exercising too intensely. Muscles are more prone to spasms when fatigued, and heat illnesses generally occur in people who aren’t used to exercising in the heat and who continue to work out even when feeling unwell.

People with diabetes are also more likely to have electrolyte imbalances (e.g., sodium and potassium) to start with, including hyponatremia associated with extended hyperglycemia (6). As discussed in a recent article (7), an increased risk of electrolyte disturbances with diabetes can result from poorer blood glucose management, diabetes medications (some of which alter electrolyte balance), and organ damage associated with diabetes (such as nephropathy).

When it comes down to it, preventing overhydration during exercise is likely more important that worrying about the effects of dehydration.  Use thirst as your guide when you exercise, and avoid consuming excess fluids, especially during prolonged workouts or sporting events. Also, keep your blood glucose levels in better control overall prior to engaging in any activities to ensure that hyponatremia is not an issue.

References:

  1. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med. 2015 Jul 30. pii: bjsports-2015-095004. doi: 10.1136/bjsports-2015-095004. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/26227507)
  2. Dugas J. Sodium ingestion and hyponatraemia: sports drinks do not prevent a fall in serum sodium concentration during exercise. Br J Sports Med. 2006 Apr; 40(4): 372. doi: 1136/bjsm.2005.022400 PMCID: PMC2577547 (http://www.ncbi.nlm.nih.gov/pubmed/16556798)
  3. Miller KC, Mack GW, Knight KL, et al. Three percent hypohydration does not affect threshold frequency of electrically induced cramps. Med Sci Sports Exerc. 2010 Nov;42(11):2056-63. doi: 10.1249/MSS.0b013e3181dd5e3a. (http://www.ncbi.nlm.nih.gov/pubmed/20351595)
  4. Braulick KW, Miller KC, Albrecht JM, Tucker JM, Deal JE. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2013 Jul;47(11):710-4. doi: 10.1136/bjsports-2012-091501. (http://www.ncbi.nlm.nih.gov/pubmed/23222192)
  5. Laursen PB, Suriano R, Quod MJ, et al. Core temperature and hydration status during an Ironman triathlon. Br J Sports Med. 2006 Apr;40(4):320-5; discussion 325. (http://www.ncbi.nlm.nih.gov/pubmed/16556786)
  6. Palmer BF, Clegg DJ. “Electrolyte and Acid-Base Disturbances in Patients with Diabetes Mellitus.” N Engl J Med. 2015;373(6):548-59. (http://www.ncbi.nlm.nih.gov/pubmed/26244308)
  7. Beware: Diabetes Results in Significant Electrolyte Disturbances, Diabetes In Control, Issue 798, September 11, 2015 (http://www.diabetesincontrol.com/articles/53-diabetes-news/18464-beware-diabetes-results-in-significant-electrolyte-disturbances#unused)