Risks

Hypoglycemia

As with other effective antidiabetic treatments, exercise has risks, especially in patients who maintain good glycemic control. These risks can be reduced, however, by applying increased care in exercising and its timing. Patients who engage in rigorous activities such as team sports can experience a dramatic hypoglycemic reaction either at the time of the activity or later that night. This risk can be prevented by anticipating and monitoring glucose during exercise. The hypoglycemia is a result of energy expended as oxidized glucose and fatty acids and the latent effects of exercise, which improve muscle blood flow and insulin sensitivity for hours, further facilitating glucose uptake. All these phenomena accelerate plasma glucose clearance, which may require decreasing antidiabetic therapies, especially insulin dosages, to prevent a late, insidious decline in glucose. Understanding all the effects of a particular exercise allows adjustments in treatment and nutrient supplementation.

Hyperglycemia

Rigorous exercise undertaken when insulin levels are insufficient and glycemic control is unsatisfactory will stimulate a stress reaction in which epinephrine activates glycogenoly-sis. If insulin is insufficient to signal muscle utilization of this hepatic outpouring of glucose, marked hyperglycemia results. Ketosis may also occur as lipolysis, stimulated by the sympathetic nervous system, is unregulated. To avoid this diametrically opposed reaction, rigorous exercises should be initiated only when the blood sugar is known to be under control. The more intense the activity, the more monitoring and nutritional supplementation are necessary. However, overeating in response to exercise is not appropriate.

Complications Associated with Heart and Microvasculature

There are also organ-specific risks of exercise in diabetes. Many cardiac patients are found to be unaware of their type 2 diabetes; almost all long-term patients with diabetes have cardiac dysfunction, often "silent ischemia."

Retinopathy and Neuropathy

Rigorous exercise that elevates blood pressure can exacerbate exudative and proliferative retinopathy. These findings may limit exercise to low-intensity activities such as walking, which is safe and effective, even in patients with reduced cardiac function.

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