Chapter 16
IN THIS CHAPTER
Grasping how diabetes combined with other conditions can impact your workout needs
Working around central or peripheral nerve damage
Choosing activities to exercise with cardiovascular disease
Staying active in spite of diabetic retinopathy
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.
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.
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.
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.
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.
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.
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).
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:
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.
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.
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.
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:
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.
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.
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
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.
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.
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.
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.
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).
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.
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.
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?
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:
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.
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