Algorithm for Exercise in Patients with Type 2 Diabetes

1. Algorithm for Exercise in Patients with Type 2 Diabetes Diagnosis Diabetes Mellitus FPG  126 mg/dL HbA1c ≥ 6.5% Diagnosis: Impaired Fasting Plasma Glucose (FPG) 100-125 mg/dL Patient screening/risk assessment Proper footwear (1) High-risk patients should be encouraged to start with short periods of low-intensity exercise & increase the intensity & duration slowly. Is cardiovascular disease present? Yes No Does patient have proliferative Retinopathy (PDR) or severe non--PDR Yes Advise low intensity/low impact exercise (3,4) Vigorous aerobic or resistance exercise may be contraindicated. Advise low intensity/low impact exercise (4) Advise to wear proper footwear & examine feet daily. Yes Does patient have vascular/orthopedic problems? High-risk patients should be encouraged to start with short periods of low-intensity exercise and increase the intensity and duration slowly. Routine screening with exercise stress test is not recommended Does patient have one or more major risk factors such as: hypertension, smoking, hyperlipidemia, or family history of premature CVD, or presence of micro/macroalbuminuria? Yes Is patient’s age < 35 yrs. Is patient’s age  35 yrs. In the absence of contraindications, adults with type 2 diabetes should be encouraged to perform resistance training at least 2x per week, in addition to aerobic exercise Advise moderate or vigorous activity Adapted from: Diabetes Care, vol. 36, Supplement 1, January 2013 • Advise moderate physical activity • Routine screening is not recommended for asymptomatic diabetes patients. Providers should assess for conditions that might contraindicate certain types of exercise, or predispose to injury, such as uncontrolled BP, severe autonomic/peripheral neuropathy or unstable proliferative retinopathy (see reverse side for definitions) Updated 2/13

2. Exercise Algorithm (continued) • Recommendations for Exercise Tolerance Test • (1) Proper footwear (socks, shoes, insoles) to prevent injury. • (2) Based on the clinical context in which they occur, if your patient • has any of the following signs or symptoms of cardiovascular or • metabolic disease, consider an exercise tolerance test (ETT) before • recommending moderate or vigorous activity: • Pain, discomfort (or other anginal equivalent) in the chest, neck, jaw, • arms or other areas that may be ischemic in nature. • Shortness of breath at rest or with mild exertion • Dizziness or syncope • Orthopnea or paroxysmal nocturnal dyspnea • Ankle edema • Palpitations or tachycardia • Intermittent claudication • Unusual fatigue or shortness of breath with usual activities • Any macrovascular or microvascular disease • Peripheral vascular disease • (3) Moderate activity is recommended to achieve physiologic improvement • (4) Orthotics as indicated • If your patients are “apparently healthy” and have fewer than two major risk factors for cardiovascular disease (CVD), then they are categorized by age: • For men and women under 35 yrs. of age, there are no limitations. They can safely begin or continue a program of moderate or vigorous activity. • Patients  35 yrs., it is safe to limit your recommendations to moderate activity (55% to 70% maximum heart rate) for both genders. Patients in this group who wish to participate in vigorous or competitive activities should be considered for an ETT screening. • If your patient has one or more major risk factors for cardiovascular disease, they should undergo an ETT before beginning a moderate exercise program. • It is important to underscore the fact that the majority of your patients, regardless of risk factors, can and should be encouraged to start or continue a program of regular moderate physical activity. • Definitions • Low Intensity/Low Impact Activity - includes activities like walking, housework light gardening, light yard work and social dancing • Moderate Intensity Activity - includes activities like brisk walking, vigorous gardening, slow cycling, aerobic dancing, doubles tennis or hard work around the house Seewww.mainehealth.org/diabetesfor additional diabetes management algorithms (Adapted from the Texas Diabetes Council 2001) Updated 2/2013