Exercise Right for Diabetes -- In-Depth Doctor's Interview
Reported July 4, 2005

TOPIC: Exercise Right for Diabetes

How many people have diabetes?

Frickman: I think 16 million have diabetes -- 8 million people diagnosed and 8 million people undiagnosed. I think it accounts for about 10 percent of the total medical care budget.

Give me a little background on diabetes.

Frickman: Type 2 diabetes is about 99 percent of diabetes, which usually occurs in adults but they have been finding it in the younger populations. The risk factors for diabetes include genetics and age which you don’t have any control over, but there are things like diet, exercise and stress that can combine to actually cause diabetes. Diabetes is a disease where your pancreas either isn’t producing enough insulin or the insulin it’s producing is resistant. Exercise lowers the insulin resistance so the insulin actually works better.

How important is exercise for people with diabetes?

Frickman: The example I use when I teach the classes is that insulin attaches to the cell wall so blood sugars can move into it, but when you exercise the blood sugars go into the cells automatically without any insulin. You have to have insulin in the tissue, so the amount of exercise you do can have a significant impact on blood sugars going into the cells. One of the examples I use is to the class is, who uses less insulin, athletes or non-athletes? Athletes use less insulin because they are exercising more, which they used to call that insulin sparring. So the more active you are and the more exercise you do, the more it’s going to help control your blood sugars and the insulin that you have is going to work better. So I have an 85-year-old lady who exercises, and she calmly comes in with a blood sugar of 250. She has lots of insulin resistance, but after she has done about an hour of moderate exercise, her blood sugar will be 100. So she’ll drop 150 points with an hour of moderate exercise. Experts say a single bout of exercise will help lower your blood sugars for 24 to 72 hours, and that’s why the American Diabetes Association, who writes a lot of the diabetes criteria, suggests you exercise at least 30 minutes three times a week to have an impact on lowering your blood sugars.

If you have diabetes, what are some of the concerns and risks before you go out and exercise? What should you know?

Frickman: Your biggest concern with exercising and having diabetes is having a low blood sugar or hypoglycemia. The medication is causing your blood sugar to lower as well as the exercise so that double impact could significantly lower your blood sugars. So, we tell people they need to exercise when their blood sugar is highest, and their blood sugar is usually highest an hour to two hours after they eat a good meal. Doing that will help offset going too low with exercise. Going too low is probably one of your biggest risks, and that’s why we tell people in the classes why monitoring their blood sugars is so important. We have people monitoring their blood sugars before exercise and after exercise to make sure they are at least high enough to exercise. Maybe they need to eat some more food to get their blood sugars back up again.

What are the numbers where you know you should not exercise?

Frickman: In the classes, we usually tell people if there is an unsupervised exercise program they need to be at least 100, and sometimes that doesn’t hold true either. They shouldn’t exercise in an unsupervised program if their blood sugars are above 250 because the stress of the exercise and the high blood sugar could actually cause their blood sugars to go up. I’ve seen people exercise over 250 in a supervised situation, they have already eaten their meal, and they will actually drop. But there is that concern that the stress of exercise can actually cause the blood sugars to go up.

So exercise causes stress?

Frickman: Exercise is a good stress. Yes, there are instances not to exercise because of that stress, and I'll usually tell people if their blood sugar is too high, if you’re sick, if it’s too cold or too hot outside, that all those are stress and actually could cause your blood sugars to go up.

Is there an optimal time of the day for diabetes to exercise?

Frickman: For diabetics, not necessarily. Statistics prove that if you exercise first thing in the morning, you are more likely to adhere to a long-term exercise program because you get it out of the way. But I have some people who exercise after lunch in the early afternoons, and they exercise in the evenings. The risk of exercising too late in the evening is that the exercise gives you more energy, and some people have trouble falling asleep. You also risk that your blood sugar is going to continue to drop after you’re through exercising, so there is that risk if you exercise too late in the evening that you could risk going too low while you’re sleeping, which is a big concern.

Is there a concern with exercising in the morning because insulin is higher in the morning?

Frickman: There are people who do have diabetes whose blood sugars are higher in the morning because of the dawn phenomenon. You intuitively want to wake up your body in the morning with a burst of sugar, so your liver drops sugar into your bloodstream to kind of give energy for your body to wake up. So some folks will have higher blood sugars in the morning, but it’s not really a big concern if they’re within their guidelines of being under 250. If they’re over 300, they probably need to go see their doctor and get their medication adjusted because they’re having that problem first thing in the morning.

Because they have a bigger concern then exercise?

Frickman: Yes. That’s why I usually refer people back to their doctor if they have those types of wild swings.

Do you have diet guidelines for how many carbohydrates, proteins and fats people with diabetes should be consuming so they can exercise?

Frickman: We are telling people to exercise when their blood sugars are highest so they are going to eat one of their main meals before they come in. They are going to eat their normal breakfast, their normal lunch, or if they exercise in the afternoons, we are going to have them eat at least a snack. And if their blood sugars aren’t at least 100, you know they are either not eating enough or they are over medicated. We need to reduce their medication so that their blood sugars are higher than that. I can give you an instance of a lady who started exercising, and she ate a normal breakfast, about 45 grams to 60 grams of food, her blood sugar was 160, and she exercised moderately for 45 minutes, then her blood sugar went down to 110. So we’re not concerned because our guidelines say it has to be over 100. Thirty minutes later she calls me up when she gets home, and her blood sugar is 60. So, obviously she had to eat something to get her blood sugar back up again, but we don’t want that to occur next time she comes in and exercises. What do you think her options are? What are causing her blood sugar to go low is the exercise and the medication. So what we do is call her doctor up and reduce her medication so that she doesn’t have those lows from exercise. She has been able to cut her diabetes medication by 75 percent by her losing 50 pounds and by continuing to exercise.

What does stress do to blood sugar levels?

Frickman: Your stress could elevate your blood sugars. The examples I give with my folks is take their blood sugar when they get on the interstate at rush hour and take their blood sugar when they get off the interstate at rush hour and invariably they all say their blood sugar is going to go up. I say what would cause your blood sugar to go up? And they said the stress, and I go well where did the blood sugar come from? And a lot of them don’t know where the blood sugar came from. It comes from the liver and when the human being is put under stress, it thinks the primitive response to stress is the flight syndrome in which the liver releases sugar into the bloodstream so it gives you energy for action. Well, there is no action and so what has to happen is your pancreas has to secrete more insulin to pick up the excess sugar that your liver produced because of stress. So chronic stress, again, is one of the things that can cause diabetes, but it is also one of the things that can actually diabetics' blood sugars to go up. A lot of my folks who come during rush hour traffic or accidents, and their blood sugars are higher than normal because their liver dropped that stress. Usually after they get their exercise, their blood sugars are back down to normal, but stress can have a significant impact.

You may actually say that 70 percent of all deaths in this country are related to chronic stress. The stress doesn’t go away, it’s how we manage the stress which is the key. So I always tell folks that exercise is one good way to manage stress. So what do you do after a stressful day? People do different things, and one of the things that you could do is take a short walk to get rid of some of those stress hormones that your body produced because it thinks that it’s under danger. We are under so much chronic stress that we have to find good releases for it. Exercise, of course, is one way to do that, especially if you have diabetes.

Is there a concern with dehydration? What does dehydration do to blood sugar levels?

Frickman: Dehydration increases the blood line so your blood sugars could go up. If people's thirst mechanism is acting normally, they are going to replace their fluids, but sometimes in diabetes their thirst mechanism may be a little impaired so we try to make sure that people replace their fluids. Six ounces every 15 to 20 minutes is a good rule of thumb to replace your fluids, so make sure you’re hydrated properly before you exercise with six to 12 ounces and another six to 12 ounces after you exercise. In a kind of environment where it’s cool, people don’t have that water loss as much as if you are exercising outside where your rate of dehydration is significantly increased, so the amount of fluids you need to intake is significantly increased.

Does it matter if you are exercising in really hot or really cold weather?

Frickman: Again, that’s a stress. Really hot weather or really cold weather is a stress to the body, so it could actually trigger the liver to dump sugar because it thinks you are under stress so it could actually elevate your blood sugars.

I have had folks who go out and exercise in the hot weather, their blood sugars go up, and they couldn’t understand it. I tell them that maybe it’s so hot for your body, your body is fighting that extreme heat that your liver sees it as a stress and it dumps sugar. I tell people to exercise at a time it’s cooler, in the mornings or in the evenings, or find a place that’s air conditioned so you don’t have those extreme temperatures.

If it’s cool outside it’s easier to keep you body temperature cool, and you can spend more energy exercising and less energy keeping your body cool. In hot weather, you’ve got to spend extra energy to keep your body cool and sometimes don’t have as good of a workout. I used to have my best workouts in Florida when it rained, as long as it wasn’t thundering, because it kept my body temperature cool, and I could run farther and run faster as a result of that.

Do you have any valuable tips that you think people with diabetes should know about exercising?

Frickman: If they haven’t actually talked to a professional, I think everybody could pick up tips. You know you can pick up tips in some of the magazines that are out there. One of the philosophies through the American College of Sports Medicine is if you are exercising for health, that moderate-intensity exercise is best. A lot of people feel they have to exercise hard in order to get benefits, and they have shown that you can get benefits without exercising at a high intensity. If you want exercise for fitness, then you are maybe going to exercise a bit harder. Are you trying to be an athlete, to maintain health, or just to be fit? You almost need to talk to someone who has expertise, and I was trained through the American College of Sports Medicine. I think that’s one of the bodies of knowledge that has been around longer than any other group of exercise knowledge that passes the research on to us so we can apply it. Strength training is very important. A lot of people need to exercise their upper body because they lose lean muscle mass as they age, and the more total body parts you exercise the more fit you are going to be. In the case of people with diabetes, the more their blood sugar is going to drop because now they are exercising more muscle groups. So we actually cut down on the strength training to one set. Do one good hard set.

Why do you concentrate your work in diabetes and exercise?

Frickman: To go way back I was diagnosed with hip Perthes when I was 2. 5 years old, which is a softening of the hip. Back then they didn’t know what to do, so they put you in a hospital in a leg trench. So for two and half years, I sat in a hospital with my leg in traction. On the floor I was on, there was a boy who had an iron lung, and physical therapy was always going over to him helping him with breathing exercises. One day he came over and did some manipulation with my leg, and I said, "Why are you helping me?" He says I’m helping you because it’s going to make your leg strong. He says remember that I’m helping you and maybe you can return it someday. I can remember the hallway. I got it in the other leg, and I didn’t walk until I was 9 years old. So I’ve always been involved in sports. I broke my leg a couple of times playing high school basketball. When I transferred to the University of South Florida, I played tennis and basketball and volleyball. I ended up teaching school and coaching. I got burned out very quickly in the teaching professions, so I worked at a hotel resort as the recreation director. They had a health spa, and I got into the recreation fitness. I then worked my way over to Orlando to run the Citrus Athletic Club. Florida Hospital came to me and asked me if I would lecture to them on losing weight. I talked to the woman that hired me and pretty soon I developed the intramural softball, basketball and volleyball program for the hospital employees. They opened up the Diabetes Center about 10 years ago, and the woman who developed the program asked me if I wanted to work some at the diabetes center with the exercise program.

I think that childhood experience of being handicapped and the orthopedic issues that I’ve had through my life has helped me be empathetic towards people . I’ve been an asthmatic my whole life so I have certain health concerns and one of the things of working here with people that have knee replacements, hip replacements, diabetes issues, bypass surgeries, congestive heart failure is despite those challenges you can still exercise and have a high quality of life. I found that a lot of those folks take better care of themselves then the employees. They come and go and have such high stress they don’t know the value of exercise.

If you would like more information, please contact:
Paul Frickman
Exercise Physiologist
Florida Hospital Diabetes Center
(407) 303-2552
Paul.frickman@flhosp.org