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FITT principles apply as for the post-MI group. Special attention is required for participants who are on insulin or oral hypoglycaemic agents (OHA). Awareness by the exercise leader and participant of the potential for both hypoglycaemia and hyperglycaemia within an exercise situation is essential. Any planned new physical activity should be discussed with the diabetic CR participant and the diabetes care team (Diabetes UK, 2003). After a cardiac event, metabolic stress may induce latent diabetes or can worsen the control of pre-existing diabetes. Therefore, it is essential that diabetes is well controlled prior to the individual commencing exercise. If a participant is newly diagnosed with either type I or type II diabetes, it is advisable that they do not exercise alone until they are able to monitor their response to exercise.

Autonomic and peripheral neuropathies are common in diabetic patients. These neuropathies affect sympathetic and parasympathetic activity, and therefore HR and BP response to exercise may be altered. Sudden changes in position need to be avoided, i.e. lying to standing, in order to avoid ortho-static/postural hypotension.

With peripheral neuropathies, loss of sensation may make pulse palpation difficult, so that RPE scale may be the most appropriate method of monitoring. Gripping of equipment may be problematic due to this poor sensation, and alternatives need to be offered, for example, dumbbells with hand straps. Diabetic patients with peripheral neuropathies may not feel the pain from blisters, so advice should be given to patients on well-fitting training shoes. Feet should be examined regularly, and any friction or nail problems treated immediately or referred to a podiatrist.

Another side effect of diabetes is macro/micro vascular disease. As a result of this, diabetic patients may be more prone to silent ischaemia and peripheral vascular disease. Silent ischaemia may only be detected on their ETT result. Diabetic patients should be closely monitored by the exercise team to assess for increasing breathlessness, which may indicate worsening of their condition in the absence of angina symptoms.

Hypoglycaemia

Insulin may need to be adjusted on exercise days to avoid hypoglycaemia during or after exercise. Participants should ensure that their exercise partner or exercise leader knows when they are taking their insulin/OHA and what to do in the event of a hypoglycaemic reaction. Insulin regimens can be complicated and must be individualised.

In order to check for signs and symptoms of hypoglycaemia, diabetics on insulin or on OHA should monitor their blood glucose levels before, during and for the first hour or more after exercise. This again should be following advice from the diabetic care team. Delayed hypoglycaemia can occur up to 36 hours after intense activity. This may be avoided by adjusting carbohydrate intake at meal and snack times (Diabetes UK, 2003). Close monitoring is essential, as exercise will alter blood glucose levels. During exercise, the activation of muscle contraction facilitates the uptake of glucose, much like insulin, by making the muscle cells more permeable or allowing glucose to pass into the cells more easily (Ivy, 1987).

For those diabetic participants who inject insulin, the injection site should be standardised and should avoid an exercising limb, since injecting into an exercising muscle may cause the insulin to be absorbed faster than usual. The abdomen area is ideal and least likely to affect performance.

Exercise should be avoided when insulin is at its peak effect. After exercise, the body essentially enters a fasted state, where glycogen stores in muscle and liver are low and hepatic glucose production is accelerated. This is why all diabetic patients on insulin or OHA should have rapidly absorbable glucose drinks and complex carbohydrates readily available, as blood glucose levels can fall during exercise. It is useful to have a selection of these foods and drinks available at all classes.

Hyperglycaemia

Hyperglycaemia is defined as an abnormally high level of glucose in the blood. If a participant has a blood glucose level >300mg/L than normal, physical activity should not be undertaken until glucose levels have stabilised. Diabetic specialists should advise participants on how to manage their blood sugar levels and how to test for ketones, which are a byproduct of incomplete metabolism (Diabetes UK, 2003).

Participants need to consult their diabetic care team for advice on adjusting their insulin and carbohydrate intake. As, potentially, exercise intensity continues to progress, ongoing advice should be sought from and provided by the diabetic care team. (See more on diabetes in Chapter 6.)

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