Role and management of exercise in diabetes mellitus.

As more is understood about the physiology of exercise, in both normal and diabetic subjects, its role in the treatment of diabetes is becoming better defined. Whereas people with diabetes may derive many benefits from regular physical exercise, there are also several hazards that make exercise difficult to manage. In type I (insulin-dependent) diabetes, there are risks of hypoglycemia during or after exercise or of worsening metabolic control if insulin deficiency is present. Type II (non-insulin-dependent) diabetic patients treated with sulfonylureas are also at some increased risk of developing hypoglycemia during or after exercise, although this poses less of a problem than with insulin treatment. In individuals treated by diet alone, regulation of blood glucose during exercise is usually not a significant problem and exercise can be used as an adjunct to diet to achieve weight loss and improved insulin sensitivity. When obese type II diabetic patients are treated with very low calorie diets, adequate amounts of carbohydrate must be provided to ensure maintenance of normal muscle glycogen content, particularly if individuals wish to participate in high-intensity exercise that places a heavy workload on specific muscle groups. On the other hand, moderate-intensity exercise such as vigorous walking can be tolerated by individuals on very low calorie, carbohydrate-restricted diets after an appropriate period of adaptation. A number of strategies can be employed to avoid hypoglycemia in type I diabetic patients, and both type I and II diabetic patients should be examined carefully for long-term complications of their disease, which may be made worse by exercise. These considerations have led many diabetologists to consider exercise beneficial in the management of diabetes for some individuals but not recommended for everyone as a necessary part of diabetes treatment as in the past. The goals should be to teach patients to incorporate exercise into their daily lives if they wish and to develop strategies to avoid the complications of exercise. The rationale for the use of exercise as part of the treatment program in type II diabetes is much more clear than for type I diabetes; regular exercise may be prescribed as an adjunct to caloric restriction for weight reduction and as a means to improve insulin sensitivity in the obese insulin-resistant individual.