Dual Payoff of Physical Activity and Exercise: Manage Diabetes and Reduce Heart Disease Risk

During a healthcare visit, your patient has questions for you:

Jeannie, a woman in her 70s with atrial fibrillation, has been recently diagnosed with type 2 diabetes (T2D). She tells you that she would like to lose some excess weight and wants to join her neighbors during their morning walks around the block. She is concerned about how her heart and her “bad knee” will handle the new activity and wants to know if you think it is safe to exercise. She also asks how exercise might affect her management of her diabetes. What advice should you offer?

Finding Motivation to Move

Before exploring the benefits of movement, it is important to distinguish between physical activity and exercise. The American Diabetes Association characterizes them in the following ways:

• Physical activity is a more general term for movements that increase the use of energy.
• Exercise is a more specific term for structured physical activity that is designed to enhance physical fitness.

Both are integral parts of a sound diabetes management plan, as well as routine care prescribed to people who have or are at risk for cardiovascular disease. As noted in a journal review, nonpharmacological interventions for the management of hypertension and cardiovascular disease in people with diabetes often focus on:

• Achieving and maintaining a healthy weight
• Reducing sodium intake
• Eating according to the Dietary Approaches to Stop Hypertension (DASH) diet
• Participating in regular physical activity

Most people will probably agree that exercise is a good idea for just about everyone, but why is it particularly good for people with diabetes? An ADA article highlights the following benefits of regular physical activity:

• Reducing the risk for cardiovascular events
• Burning calories to support weight management and weight loss
• Enhancing energy available for daily life
• Improving rest and sleep
• Serving as an effective strategy to manage stress
• Improving cardiac function and efficiency
• Strengthening bones and muscles
• Increasing flexibility and improving balance
• Enhancing quality of life by reducing symptoms of mental health disorders
• Reducing blood pressure and cholesterol

The American Heart Association (AHA) tracks key health factors and behaviors—called Life’s Simple 7—that carry increased risk for stroke and heart disease. The purpose is to track progress toward the AHA 2020 Impact Goal, which is to improve cardiovascular health by 20% and reduce deaths from cardiovascular diseases and stroke by 20% by the year 2020 for all Americans. These modifiable risk factors are:

• Smoking
• Physical inactivity
• Poor diet
• Obesity and overweight
• Hypercholesterolemia
• High blood pressure
• Diabetes

Considering these factors, the importance of physical activity and exercise programs is clear.

Understanding the Link Between Diseases

Researchers note a significant correlation between diabetes and cardiovascular disease, as the high blood glucose levels that occur with diabetes can damage blood vessels and the nerves that conduct signals to the heart and systemic vasculature. This phenomenon can have some detrimental effects, as noted by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK):

• The risk of developing cardiovascular disease increases with the length of time a person has diabetes.
• Individuals with diabetes usually develop heart disease at younger ages than individuals who do not have diabetes.
• Individuals with diabetes are almost twice as likely to die from cardiovascular disease than individuals who do not have diabetes.
• The most common causes of death in adults who have diabetes are heart disease and stroke.

However, the most important relationship between these two diseases is a positive one; people can take steps to reduce their risk for cardiovascular disease as they manage their diabetes. Those steps include giving attention to what the NIDDK calls the Diabetes ABCs:

• A1C test (Keep under 7% or the recommended value provided by a physician.)
• Blood pressure (Keep ≤120/80 mmHg, according to the AHA guidelines.)
• Cholesterol (Strive to achieve the recommended levels which differ by age and sex.)
• Smoking (Stop!)

Exercise is a key component in addressing each of these steps and has many benefits for managing both cardiovascular disease and diabetes. So how should Jeannie get started?

Determining the Best Exercise Program

Exercise is physical activity that is planned, structured, and repetitive for conditioning any part of the body. All exercise programs should be planned and carried out according to each person’s age, previous physical activity level, medical condition, abilities, and desires. Some individuals who experience complications related to diabetes or cardiovascular disease will probably require more intense appraisal and assessment before implementing an exercise program.

It is important to encourage participation in physical activity even when a chronic condition or disability limits a person’s ability to comply with the recommended guidelines. The goal is to engage in regular physical activity according to each person’s ability and avoid complete inactivity, as recommended in guidelines from the U.S Department of Health and Human Services. Remind those you care for that some activity is always better than no activity.

ADA Recommendations

The ADA recommends creating variety in leisure activities, balance, and flexibility exercises. Specifically, the ADA exercise recommendations for adults with Type 1 or Type 2 diabetes (T1D or T2D) are:

• Most adults should participate in ≥150 minutes or more of weekly moderate to vigorous aerobic activity. Sessions can be separated by one day but ideally not more than two days.
• Some younger, physically fit adults may participate in a minimum of 75 minutes per week of vigorous or interval training instead. They are defined as people who can run 6 miles per hour for at least 25 minutes.
• Participate in two to three weekly sessions of resistance exercise on nonconsecutive days.
• Decrease the time spent being sedentary, especially for adults with T2D. Interrupt prolonged sitting every 30 minutes with standing, walking, and other light physical activity.
• Older adults should participate in two to three weekly sessions of balance and flexibility training exercises. These may include yoga and tai chi to increase strength, balance, and flexibility.

Aerobic activity should be at least 10 minutes in length and the goal should be 30 minutes or more of daily exercise most days of the week for adults with T2D. Daily exercise is recommended because it is linked to decreased insulin resistance for both T1D and T2D. Activity should be increased over time to reach the 150-minute goal if not already reached. It is important to remember that people with diabetes at high-risk for cardiovascular events or conditions should start with short, low-intensity periods of exercise and increase exercise as tolerated.

Resistance exercises of any kind are recommended, although heavier resistance training using free weights and weight machines can improve glycemic control and muscle strength.

Flexibility and balance exercises can have a positive impact on A1C in addition to physical strength, flexibility, range of motion, and balance.

AHA Recommendations

The American Heart Association recommends adults engage in 150 minutes per week of moderate-intensity exercise, 75 minutes per week of intense aerobic activity, or a combination of the two. These sessions should be spread throughout the week and include muscle-strengthening activity on at least two days. Any recommendations for aerobic exercise should be specifically provided by a medical professional who is familiar with the individual’s health history.

A regular program of physical activity and exercise for people with diabetes and cardiovascular disease can help reduce or even relieve many of the symptoms of both conditions. The benefits of exercise for people with diabetes include reducing the risk for cardiovascular events, among others. When you are advising people like Jeannie, always stress the importance of individually appropriate exercise programs in achieving and maintaining optimal health.