Chapter 16

Exercising with Health Complications

IN THIS CHAPTER

check Grasping how diabetes combined with other conditions can impact your workout needs

check Working around central or peripheral nerve damage

check Choosing activities to exercise with cardiovascular disease

check Staying active in spite of diabetic retinopathy

check Deciding how to be active with kidney issues

So you know you need to be more physically active, but you have [insert your health issue here] to worry about, which makes you choose to stay on the couch instead. Is it loss of sensation in your feet that makes you more unstable while walking? A diagnosis or symptoms of heart disease? Some early changes in your eyes or your vision that you see as a barrier to exercise?

Certain health complications or other physical conditions can impact your ability to exercise safely and effectively. Though not usually entirely limiting, some diabetes-related health complications require adaptations in your physical activity choices.

Regardless of the health issue or issues you may be dealing with, this chapter shows you that you can find a way to be more active, both safely and effectively. It’s just a matter of making some adjustments or taking some precautions to make sure that you don’t injure yourself or cause your condition to get worse. You’ve got this.

Dealing with Health Complications

Although 85 percent of older adults over 65 have a health problem that they may view as a deterrent, anyone with a chronic health problem or two generally responds well to exercise training. But having diabetes does carry some additional risks.

As you may already know, diabetes is associated with a number of short-term and long-term health complications that require you to understand them to exercise safely. The leading cause of death in all Americans is heart disease, regardless of whether you have diabetes. You are at greater risk for developing complications like stroke, high blood pressure, vision loss, kidney disease, joint problems, nerve damage, foot ulcers, and lower-extremity amputations that may affect your choice of activities or how you approach them.

remember Keeping your blood glucose as close to normal as possible is the best way to prevent many, if not all, of these potential health problems. That’s where regular exercise, a healthful diet, effective use of diabetes medications, and a blood glucose meter come in handy.

tip If you’re just getting started, you may want to consult with your health care team or an exercise professional to help you develop a physical activity plan that factors in your diabetes management, complications, heart disease risk, other health problems, personal goals, and exercise preferences. If you choose to go it alone, simply follow the exercise guidelines published by the American Diabetes Association (accessible online at http://care.diabetesjournals.org/content/39/11/2065) and respect your potential limitations while staying as physically active as possible.

Exercising Safely with Nerve Damage

Loss of sensation or pain in your feet (or hands) is called peripheral neuropathy, and it increases your risk of damaging your feet or lower limbs during exercise. If you have damage to other nerves in your body (autonomic neuropathy, affecting nerves in the spinal cord), you can experience different issues related to this condition. In this section, I explain why being active may help and how to exercise safely if you have either of these issues.

Working around damaged feet and legs

When you’re missing the usual symptoms of pain or discomfort from impact on your feet or friction and pressure from footwear, you’re much more likely to get an irritated area on your foot without being aware of it. In some cases, a simple blister can progress into a full-blown infected abscess or ulcer and ultimately result in an amputation if not detected and treated in time.

Even if you haven’t lost much sensation in your feet that you know of, developing a foot ulcer on the bottom (plantar) surface or sides of your feet may be a sign you have some peripheral neuropathy already. Your doctor can check for signs of this condition or refer you to a specialist if necessary.

tip When staying active, inspect your feet daily for sores, blisters, irritation, cuts, or other injuries that can develop into ulcers. If you can’t easily pull your feet up to look at the bottoms, place a mirror on the floor and hold your feet over it to inspect them yourself or ask someone else to check them for you.

warning Have a doctor look at any unusual changes in the skin of your feet sooner rather than later. You can avoid the possibility of gangrene and possible amputation of your toes or your foot if you get problem areas treated early.

Picking the right socks and shoes

If you’ve lost sensation in your feet, use shoes with silica gel or air midsoles (the middle section of the shoe that provides the most stability and shock absorption). Also, wear polyester or cotton-polyester blend socks to prevent blisters and keep your feet dry during physical activities.

warning Pure cotton socks aren’t recommended for exercise because they tend to get and stay wet, which can lead to irritation and injury of your feet.

Choosing appropriate activities

Although being regularly active can’t fully reverse nerve damage in your feet, exercise can slow its progression and prevent your getting more out of shape from sitting around all the time. Exercise may improve circulation in your lower legs and feet and help prevent ulcers.

If you’ve lost most or all of the sensation in your feet, you may need to switch to doing more activities that minimize potential trauma to your lower extremities. Aquatic activities like swimming, pool walking, and water aerobics are good choices, but they’re not an option if you have any open sores. You can also do rowing, upper body cycling (using an arm crank), chair exercises, stationary cycling, yoga, seated resistance training, and abdominal work.

tip Work on improving your flexibility and balance to prevent falls, which are more common if you lose sensation in your feet. Chapters 12 and 13 offer balance and flexibility exercises, respectively.

warning If you have unhealed ulcers, minimize walking or weight-bearing activities until they’ve fully healed. While they’re healing, keep your feet clean and dry, avoid swimming, stay off your feet, and inspect them daily.

You don’t need to avoid all activities done on your feet if you’ve lost sensation, but not doing them daily (cross-training) helps. Combined resistance and interval exercise training are both good to do occasionally. All these activities — both the ones that make you carry your weight and those that don’t — can improve your fitness, muscle tone, balance, and awareness of your lower extremities.

If your peripheral nerve damage causes dull, shooting, or throbbing pain in your extremities after you go for a walk or do other weight-bearing activities, switch to others that don’t cause you lasting pain or discomfort. If the pain is constant, you may need to seek treatment for painful diabetic neuropathy or be tested for peripheral artery disease (more on this condition later in this chapter).

Staying on top of central nerve issues

If you have damage to your central nervous system (autonomic neuropathy), it can manifest in a variety of ways, almost all of which may impact your ability to be active safely and effectively. For example, you may be more likely to experience silent ischemia (reduced heart blood that doesn’t have any other symptoms), which can result in a “silent” or symptomless and undetected heart attack. Your chances of dying suddenly during exercise are higher after your heart has become unresponsive to nerve impulses (a central nerve condition known as cardiac autonomic neuropathy, which is discussed more below), particularly if you have some underlying heart disease present.

Here are some possible conditions that result from central nerve damage and guidelines on what you should do to stay safe during exercise:

  • Cardiac autonomic neuropathy: This is the most concerning of all the central nervous system damage that can occur when your blood glucose stays elevated over time. If you have this condition, you may have an elevated heart rate at rest (for example, 100 beats per minute or higher rather than the normal 72), and it may keep your heart from beating as fast as normal during exercise. Keep the following points in mind:
    • If you have cardiac autonomic nerve damage, take a conservative approach to exercise and physical activities.
    • Have your doctor test your heart’s responses before you start an exercise program so you know how exercise affects your heart rate.
    • Warm up for at least ten minutes and cool down longer than normal, particularly when you’re doing strenuous activities.
    • Don’t use heart rate to monitor your exercise intensity because it may be lower than expected during activities; instead, use a subjective rating (such as “somewhat hard” for moderate) or the talk test (which I cover in Chapter 4).
  • Orthostatic hypotension: When you change your body position rapidly during an activity, your blood pressure may drop (a condition called orthostatic hypotension) and make you feel lightheaded or dizzy, or you may faint.
    • Avoid activities with rapid postural changes (like racquetball) because your blood pressure may not respond fast enough and you can faint.
    • Try to stay fully hydrated during exercise to remove the potential for dehydration to add to these symptoms.
  • Impaired thermoregulation: Your body is less able to move blood around to help you cool down, making you more likely to overheat and get dehydrated during exercise.
    • Don’t exercise in extreme hot or cold environments because you may not be able to regulate your body temperature well at either end of the spectrum.
    • Stay fully hydrated by drinking fluids during exercise, especially when you’re exercising in hot and humid conditions.
  • Gastroparesis: If your ability to digest food has been affected, any carbohydrate you use to treat low blood glucose during exercise may take longer to work, and your low may get more severe. Consider the following:
    • Eat only small portions and avoid eating a large meal before exercise; the latter may delay the emptying of food from your stomach.
    • Check your blood glucose before and after exercise because you’re more likely to develop low blood glucose.
    • To treat a low, take glucose tablets before your blood glucose goes down to 100 mg/dL to prevent severe hypoglycemia.

Being Active with Vessel Disease

If you have diabetes or prediabetes, you may also already have the beginnings of cardiovascular disease, which can cause heart attack, stroke, lowered blood flow to your heart, or reduced leg blood flow. When stable, none of these conditions should prevent you from exercising, but you may need to change up what you’re doing or take other precautions to avoid problems.

Individuals with diabetes in supervised “cardiac rehab” exercise programs engage in various activities. You may choose to join such a program if you know you have cardiovascular disease, or you may exercise on your own or with others.

remember Regular exercise helps improve blood flow through your body and reduce the severity of cardiovascular changes you may already be experiencing.

Heart disease

Heart disease — which is caused by plaque formation in the coronary arteries and reduced blood flow to the heart muscle — has been associated with insulin resistance and inflammation. But it may not be as directly related to how well your blood glucose is managed. If you have any symptoms related to heart disease you need to take precautions to exercise safely.

Dealing with reduced blood flow to your heart

If you experience angina (chest pain) due to reduced blood flow to your heart muscle (a condition known as ischemia) during an aerobic activity like walking, you may want to do a different activity.

You probably won’t have the same problem during resistance workouts. Lifting a heavy weight 10 to 12 times may increase your blood pressure more than aerobic exercise does, but it doesn’t raise your heart rate as much. Your blood pressure rises more and sends more blood to your heart muscle during this type of workout than an aerobic one.

remember If you have some coronary artery blockage from plaque buildup, moderate weight training may be a safer activity for you than most higher intensity aerobic ones, and resistance training is recommended nowadays for almost everyone to increase strength and preserve muscle mass.

warning If you prefer walking or another aerobic activity but experience angina when active, keep your heart rate about ten beats per minute lower than the point at which you start to experience pain or tightness in your chest during the activity. For example, work no harder than 120 beats per minute if you have symptoms that start at 130 beats.

Recognizing that you’re having a heart attack

Exercising only slightly increases your risk of having a cardiovascular event like a heart attack (myocardial infarction) while you’re doing it. But training regularly lowers your chances, so being active is still always better than being a couch potato.

That said, know the usual warning signs of heart attack:

  • Chest discomfort: This discomfort in the center of the chest may feel like bad indigestion, uncomfortable pressure, squeezing, fullness, or acute and stabbing pain. It may last or be intermittent.
  • Discomfort elsewhere: The pain or discomfort may be localized somewhere other than your chest. Pain radiating down one or both arms or the back, neck, jaw, or stomach is known as referred pain because it originates in your heart due to lack of oxygen but is felt elsewhere.
  • Shortness of breath: This warning sign can occur with or without chest discomfort and is symptomatic when it’s unusual or unexpected.
  • Other symptoms: Sudden sweating, nausea and vomiting, lightheadedness, and undue, unexplained fatigue are all signals you may be having a heart attack.

warning If you experience a sudden, unexplained change in your ability to exercise (such as extreme fatigue that comes on quickly), without any other symptoms, immediately stop exercising and consult with your physician as soon as you can to rule out silent ischemia.

warning Don’t delay in calling 911 or seeking other immediate medical attention if you’re experiencing any of the signs or symptoms of a heart attack. Treatment in the first few minutes is critical for surviving a major cardiac event with minimal lasting problems.

High blood pressure and stroke

Being regularly active doing aerobic exercise lowers the potential impact of most other cardiovascular risk factors, including high blood pressure, regardless of what type of diabetes you have.

High blood pressure, or hypertension, is associated with elevated levels of insulin in your body, which are common with insulin resistance. Getting up off the couch and exercising regularly can lower your blood pressure and reduce how much insulin is in your bloodstream — both of which are very good for your overall health.

Exercising safely with high blood pressure

If you have high blood pressure, you may need to avoid high-intensity or heavy resistance exercises that can cause your blood pressure to rise dangerously high and bring on heart attack or stroke. Limit your involvement in heavy weight training; near-maximal exercise; activities that require intense, sustained contractions of the upper body, such as water-skiing or windsurfing; or any exercise that involves holding your breath.

tip Appropriate blood pressure medications should help keep your pressures lower during activities, so take them as prescribed.

Recognizing that you’re having a stroke

Watch out for stroke warning signs, which all have a sudden onset in common. Go to the emergency room right away for life- and brain-saving treatment within a couple of hours for the best possible outcomes if you do have any of the symptoms of a stroke.

Stroke warning signs and symptoms include sudden

  • Numbness or weakness, especially on one side of the body (for example, legs, arms, face)
  • Confusion
  • Trouble with normal speaking or understanding
  • Loss of vision in one or both eyes
  • Trouble with walking, loss of balance, or lack of physical coordination
  • Severe headache and dizziness
  • Symptoms like sweating, nausea and vomiting, lightheadedness, or undue, unexplained fatigue

warning To lower your risk of stroke, if your systolic blood pressure (the higher number) is above 200 mmHg or your diastolic blood pressure (the lower one) is above 110 mmHg, avoid exercising until they’re lower.

Peripheral artery disease (PAD)

Another form of cardiovascular disease, peripheral artery disease (PAD), is a common circulatory problem that limits blood flow to your legs and arms. Plaque can form in any artery, not just the ones feeding the heart and brain, and PAD usually occurs in peripheral arteries in the legs.

Knowing whether you have PAD

Pain in your lower legs while standing or walking is a common symptom of PAD. Measuring the blood pressure in your leg or ankle compared to in your arm is how doctors diagnose PAD. If it’s higher in your leg, you may have blockage there that is raising the pressure.

If you experience symptoms in your legs during or after physical activity and you haven’t yet been diagnosed with PAD, see your doctor to get a definite diagnosis before proceeding with your exercise program. You want to know for sure because having PAD may mean that you have widespread plaque formation in other arteries around your body.

warning If plaque in your leg arteries ruptures, it can block blood flow and cause pain, changes in skin color, sores or ulcers, difficulty walking, and even gangrene. See your doctor right away if you have any of these symptoms.

Luckily, PAD is treatable. Certain prescribed medications that lower your blood pressure can dilate your leg arteries and relieve symptoms. Surgery can also improve blood flow to your legs by bypassing blockages.

Exercising with PAD

You can get your PAD under control and maintain your normal activities. In fact, walking or other daily exercise helps you maintain optimal circulation in your legs. It may improve the blood flow to your feet, especially when combined with eating a more healthful diet and quitting smoking.

Using pain as your guide, engage in easy or moderate walking and take rest periods as needed. You may have to choose activities that don’t cause pain. If walking hurts too much, try doing seated exercises, water workouts, upper body resistance training, or stationary cycling.

Eyeing Ways to Exercise with Retinopathy

Individuals who have diabetes can develop up to eight different eye complications over time, including cataracts, macular edema, and retinopathy. You can lower your risk of getting any of these with better overall blood glucose management and limiting your post-meal spikes. All eye diseases have the potential to obscure vision and make participation in certain activities (such as outdoor cycling) more dangerous. But, luckily, they’re not usually a complete barrier to exercise. The following sections address one of the more common issues, diabetic retinopathy (caused by abnormal growth of blood vessels inside the eye back on the retina that can bleed when severe).

warning If you notice sudden, dramatic changes in your sight while exercising, stop all activity immediately and check with your eye doctor for further guidance.

Mild or moderate retinopathy

If you have diabetic retinopathy that is only mild or moderate, with no active bleeds, some precautions are necessary. Avoid activities that dramatically increase the blood pressure inside your eyes, such as heavy resistance training, breath-holding during exercise, or doing activities with your head lower than your heart.

Severe (proliferative) retinopathy

If you have severe, or proliferative, retinopathy (that is, you have growth of abnormal vessels in the back of your eyes that can hemorrhage or detach your retina), you can do exercises like swimming, walking, low-impact aerobics, stationary cycling, and other endurance exercises at a low to moderate level as long as your eyes aren’t actively bleeding internally. You should be able to see when such hemorrhages occur (if your vision isn’t already totally blocked by prior bleeds that haven’t fully cleared out).

However, you must avoid certain activities until the condition has stabilized over time with treatment. Although exercise doesn’t make this eye disease worse overall, it can make hemorrhaging worse (by increasing pressure inside your eyes) or contribute to a retinal tear or retinal detachment.

warning Avoid doing these activities with unstable proliferative diabetic retinopathy:

  • Heavy resistance training
  • Running or jogging
  • Most racquet sports
  • Boxing
  • Competitive contact sports (such as basketball and football)
  • High-impact aerobics
  • Activities where you keep your head down or lower than your heart
  • Jumping
  • Jarring activities
  • Any activity that elevates blood pressure a lot

warning Never engage in moderate or vigorous exercise with an ongoing eye hemorrhage. Doing so may cause extra bleeding into your eye and further block your vision. Wait until the hemorrhage has stopped and then see your eye doctor for guidance before doing any more intense exercise.

Staying Active with Kidney Disease

Regular exercise training is recommended for anyone with diabetes-related kidney disease, regardless of how severe it is. Exercise doesn’t worsen diabetes-related kidney problems (such as nephropathy). In fact, being active may help keep such problems from progressing as fast. Letting yourself get deconditioned when you have kidney problems only adds to your level of fatigue.

What should you do to be active?

  • With kidney disease at any stage, you may have a reduced capacity to exercise. Start out with low to moderate activities rather than anything too hard and progress slowly.
  • Try to exercise daily, even if you just do easy exercise on days that you’re feeling more tired.
  • You can even exercise during dialysis sessions if you have the chance. Only avoid exercising during dialysis if certain substances in your blood (hematocrit or total red blood cell count, calcium, or potassium) become unbalanced or if you get extremely fatigued immediately afterward.
  • If you have a kidney transplant, you can safely start exercising six to eight weeks after surgery, when you’re stable and free of signs of rejection of the new kidney.

warning Exercise increases the excretion of protein and microalbumin in your urine, both of which are used as lab indicators of kidney problems. Abstain from exercising hard on a day that you’re collecting your urine to be tested. Otherwise, your results may be skewed and misinterpreted as evidence of kidney damage or disease progression when your kidneys are healthy.

Managing Exercise with Health Issues

Be prepared for the type of exercise you’re doing. For example, invest in the right shoes for the activity and dress in layers so that you can add or remove clothing if you need to. Avoiding activities that cause you any pain or that aggravate any pre-existing health problems you may have is also important.

If you’ve been mostly sedentary, the best advice is to start with mild or moderate exercise and progress slowly to prevent potential problems with any health complications. Brisk walking and other mild and moderate activities are generally safe to start on your own, but if you want to do vigorous activities, see your health care provider first to get checked for complications that certain activities may worsen.

Precautions for exercising with diabetes in addition to any health complications include the following:

  • Carry a blood glucose meter to check your blood glucose level before, possibly during, and/or after exercise, or if you have any symptoms of a low.
  • Immediately treat low blood glucose during or following exercise with easily absorbed carbohydrates like glucose tablets or regular soft drinks (see Chapter 5).
  • Inform your exercise partners about your diabetes, and show them how to administer glucose or another carbohydrate to you should you need assistance.
  • Stay properly hydrated with frequent sips of cool water. Chapter 7 has details on hydration.
  • Consult with your physician prior to exercising with any of the following conditions:
    • High blood pressure
    • Neuropathy (nerve damage), either peripheral or autonomic
    • Foot injuries (including ulcers)
    • Proliferative retinopathy or current hemorrhaging
    • Kidney disease
    • Serious illness or infection
  • Seek immediate medical attention for chest pain or any pain or discomfort that radiates down your arm, jaw, or neck.
  • If you have high blood pressure, avoid activities that cause large increases in your blood pressure, such as heavy resistance work, head-down exercises, and anything that forces you to hold your breath.
  • Wear proper footwear, and check your feet daily for signs of trauma such as blisters, redness, or other irritation.
  • Stop exercising immediately if you experience bleeding into your eyes related to unstable proliferative retinopathy.
  • Wear a diabetes medic alert bracelet or necklace with emergency contact information.
  • Carry a cellphone with you when you exercise outdoors or alone.

No matter what you choose to do to be physically active, the most important thing is that you’re doing it. So many health complications associated with having diabetes long-term are preventable with healthful lifestyle changes — including regular physical activity. Even if you’re already suffering from some of these long-term issues, you really don’t have any excuses left for not getting moving to improve your health while you’re alive.

remember The best advice is to use having diabetes as an excuse to exercise, not as a reason to remain sedentary.

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