Diabetics should be prescribed to "walk"! Italian guidelines

Recently, two Italian societies conducted a systematic review and published guidelines, suggesting that people with type 2 diabetes should be prescribed "walking" to increase physical activity and reduce sedentary behavior. [Original link]

There are reasons why people with diabetes are reluctant to move

The guidelines point out that people with diabetes have poor physical conditions, often feel tired, and have reduced aerobic capacity. Chronic high blood sugar may also cause saccharification of musculoskeletal structures, leading to tendon hardening and limited mobility. Therefore, people with diabetes are less willing to move.

But exercise helps control blood sugar and reduce the risk of cardiovascular events. In comparison, walking is simple and easy.

The American Diabetes Association recommends that most adults with diabetes should get at least 150 minutes of moderate-intensity aerobic activity at least three days per week and avoid more than two days of inactivity, or at least 75 minutes of high-intensity or interval training per week.

In addition, 2 to 3 strength training, flexibility and balance exercises should be performed to improve joint mobility and prevent falls.

The authors analyzed 28 studies and 20 randomized controlled trials and found that regular walking training, especially under supervision, can improve blood sugar control in people with type 2 diabetes and also have positive effects on cardiopulmonary function, weight and blood pressure.

Specifically, walking can reduce the level of glycated hemoglobin (HbA1c) by an average of 0.5%, reduce the body mass index by 0.91 kg/m2, reduce diastolic blood pressure by 1.97 mmHg, and significantly improve cardiopulmonary fitness.

The article points out that physical activity is beneficial and generally safe, but it does have some potential risks, such as musculoskeletal injuries, acute cardiovascular complications, and hypoglycemia.

Initial screening and assessment

Before initiating any physical activity, an initial screening should be performed with particular attention to signs and symptoms of chronic comorbidities such as cardiovascular disease, nephropathy, retinopathy, and/or neuropathy, and assessment of metabolic control.

When planning moderate-intensity exercise and/or prolonged walking, assessment for osteoarticular changes and microvascular complications is imperative.

Exercise stress testing may be indicated when cardiovascular disease is suspected or when high-intensity exercise is planned.

It is also important to assess walking ability, such as walking speed and walking distance, including the 10-meter walk test and the 6-minute walk test.

High intensity activity is not encouraged

The guidelines point out that high-intensity exercise may cause patients to not persist in exercise. There is a lot of evidence that people are more likely to persist in low-intensity activities. Therefore, it is not encouraged to recommend that all diabetic patients participate in higher-intensity activities to avoid patients not persisting.

Walking can effectively reduce weight and maintain weight, and improve blood sugar control. It should be the preferred activity for most diabetic patients, and they should insist on walking enough.

When walking, the heart rate reserve should reach 40% to 60% (the percentage of maximum heart rate minus resting heart rate), which corresponds to a self-perceived exercise intensity of 11 to 13 levels, which means feeling a little tired.

After a period of exercise, if the patient can tolerate it, he or she can try higher-intensity exercise, or alternating high-intensity exercise with rest or recovery exercise, which is called "high-intensity interval training" (HIIT).

Use wearable devices to assess heart rate

Before walking, you should stretch your upper and lower limbs to allow the joints to adapt.

Shoes and clothing for walking must combine comfort and safety, taking into account seasonal changes.

High or low temperatures increase energy expenditure, and it is recommended to reduce walking speed and shorten walking distance.

Compared with walking, Nordic Walking, that is, walking with a stick, consumes more energy, increases arm muscle exercise, and can also improve athletic ability, quality of life, cardiopulmonary function and blood lipid status, and reduce weight and chronic pain.

The response of the cardiovascular system can be assessed by monitoring heart rate. Wearable devices for monitoring heart rate have been developed over the past few decades and are accurate, reliable, and relatively inexpensive.

Severely obese people can walk with a cane

For severely obese diabetic patients, walking is also a feasible form of exercise, but they should consider reducing their pace and recovering appropriately after every 15 minutes of exercise. Walking with a cane can reduce the load on the lower limb joints.

Diabetic patients have a higher incidence of heart failure, angina pectoris, reinfarction, and sudden cardiac death, but they can also walk. However, patients with coronary heart disease or heart failure must have a designed exercise program and supervision.

The guidelines have 12 major recommendations

1. Walking can improve blood sugar control in patients with type 2 diabetes. It is an aerobic exercise and should be prescribed for most diabetic patients.

2. Walking can improve a variety of health-related problems in people with type 2 diabetes.

3. Walking can improve the physical function status of diabetic patients.

4. Walking is beneficial in preventing chronic complications in diabetic patients.

5. It is best for diabetic patients to perform walking training under supervision.

6. Combined with a variety of incentives, diabetic patients can also engage in unsupervised walking.

7. Interval training can also be used by people with diabetes, especially in younger and healthier patients.

8. Walking with a cane may have certain advantages.

9. Pay attention to where you walk and the slope of the ground.

Walking on sand or snow, or walking in water, results in increased energy expenditure compared to walking on a hard surface. Likewise, walking uphill or downhill increases energy expenditure compared to walking on flat ground. Changes in speed or grade can also affect walking.

10. Because it may affect the use of hypoglycemic drugs, attention should be paid to the effect of walking before or after meals on postprandial blood sugar, but there is a lack of evidence on this.

11. People with diabetes should not sit for long periods of time. Standing up and taking a short walk from time to time can improve blood sugar control.

12. Risk and functional status must be assessed. Asymptomatic patients receiving appropriate glucose-lowering therapy generally do not require stress testing. The 6-minute walk test can be used to assess and monitor walking ability.

Source: Moghetti P, et al. Walking for subjects with type 2 diabetes: A systematic review and joint AMD/SID/SISMES evidence-based practical guideline. Nutr Metab Cardiovasc Dis, 2020, 30(11): 1882-1898.

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