Explore concerns

Many people with health problems - and those without - have reasonable concerns about becoming more active

back
next
1
Ask

“What concerns might you have about becoming more active, if you decided to?”

Saying “if you decided to” reminds them that they are the decision maker, not you. This helps keep the discussion open and active, focusing your role on providing support.

 

For example say ‘Yes, that is a common concern’  or a reflection such as ‘you’re concerned that being more active may make you feel even more tired’ (said as a statement, not a question)

Your role is to help them feel listened to and understood rather than to immediately jump in to dismiss their concern or to offer information, advice and reassurance.  Acknowledging their views will help them to feel supported and may help them to be more receptive to any new information you might want to share with them.

Allow some space for people to talk about and explore new information, asking ‘what do you think about what I’ve just said?’ rather than asking ‘do you understand?’ which can shut things down. Ask if they need anything clarifying and what concerns they might have about how the information applies to them.

2
Share

If they mention one of these common concerns, click on it to see a useful response.

I am overweight – will exercising help me to lose weight?

Exercise alone, without concomitant dietary caloric restriction and behaviour modification, produces only modest weight loss. The most successful programs for long-term weight control in diabetes involve combinations of dietary modification, exercise, and behaviour change (Pan et al., 1997; Sigal et al., 2004)

However, even with modest weight loss there are significant benefits in regular exercise:

  • Improved glycaemic control
  • Reduced diabetic and cardiovascular complications
  • Lower blood pressure
  • Stronger bones
  • Leaner, stronger muscles

Tips you may wish to share: 

All physical activity helps and can be beneficial. Start with something gentle, like walking, gradually working up to 30 minutes a day of moderate intensity exercise, five times a week.

Moderate-intensity activity raises the heart rate and increases rate of breathing. An easy way to explain the intensity of exercise is the talk test – moderate intensity: breathing rate is increased but you can still talk.

References

Pan XR, Li GW, Hu YH, Wang JX, Yang WY, An ZX, Hu ZX, Lin J, Xiao JZ, Cao HB, Liu PA, Jiang XG, Jiang YY, Wang JP, Zheng H, Zhang H, Bennett PH, Howard BV. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care. 1997 Apr;20(4):537-44.

Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. Physical activity/exercise and type 2 diabetes. Diabetes Care. 2004 Oct;27(10):2518-39

I am worried about causing foot ulcers

In people with peripheral neuropathy, but no active foot disease, become more physically active through walking carries no additional risk of causing foot ulcers (Balducci et al., 2006).

In the presence of active foot disease (ulcers) weight bearing exercise must be avoided. Regular follow up with podiatry is recommended.

Tips you may wish to share:

Check feet regularly and wear well fitting shoes

References

Balducci S, Iacobellis G, Parisi L, DiBiase N, Calandriello E, Leonetti F, Fallucca F. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications. 2006 Jul Aug;20(4):216- 23

Are there any absolute contraindications to exercise in Type 2 Diabetes?

There are a number of conditions specific to type 2 diabetes where patients should be reviewed by a specialist prior to exercising (Holt et al., 2017);

  • Autonomic neuropathy – cardiovascular assessment is advised prior to exercise
  • Diabetic retinopathy – if proliferative or severe non-proliferative avoid vigorous exercise due to risk of vitreous haemorrhage or retinal detachment

Cardiovascular disease – enquire about symptoms and if present or concern specialist cardiologist assessment is advised prior to exercise.

References

Holt RIG, Cockram C, Flyvbjerg A, Goldstein BJ, Chen MZ, Andrews RC. Textbook of Diabetes, 5th Edition, Wiley Blackwell, Chapter 26; 351-371 (2017). ISBN: 978-1-118-91202-7

I am worried about having a 'hypo'

This is primarily a problem for people with type 1 diabetes, not type 2 diabetes, and only relevant to those on sulphonylurea or insulin.

Suggest being more active along with someone else and have a carbohydrate snack available. Doses of medication may need to be reduced or withheld on exercising days (Holt et al., 2017).

Tips you may wish to share: 

Build confidence in exercising by monitoring blood sugar reaction to exercise.

Try not to exercise within 2 hours of a meal

Seek further advice from the Diabetes Specialist Nurse

References

Holt RIG, Cockram C, Flyvbjerg A, Goldstein BJ, Chen MZ, Andrews RC. Textbook of Diabetes, 5th Edition, Wiley Blackwell, Chapter 26; 351-371 (2017). ISBN: 978-1-118-91202-7

Will I need to check my blood glucose more regularly?

Checking blood sugar is only recommend the first time you introduce a new activity, if you are on insulin or sulphonylurea.

Tip you may wish to share:

Check blood sugar levels if you are feeling unwell

I already feel tired and you want me to do more….

Becoming more active is the most important treatment for persistent fatigue as it helps with body reconditioning and boosts energy levels. It can be a way for individuals to take back some control over their health

Tips you may wish to share:

  • Encourage a slow start with a gradual build up to small bouts of activity (this just needs to be a few minutes). This can increase over time
  • Increase the number of activity sessions first, then increase the duration each activity, followed by the intensity of an activity

I am already in pain being active will just make it worse

It is normal for anyone who is not used to being physically active to experience some muscle soreness after doing a new exercise. As people become accustomed to the activity this pain will reduce.

Tips you may wish to share:

  • Ensure an adequate warm up and cool down of 5-10 minutes
  • Exercise at the time of day when pain is usually least severe

My gym said I need medical clearance before being active: am I OK to exercise?

For the vast majority of people, medical clearance is not required to safely undertake progressive, moderate intensity activity. Important exceptions to this are people experiencing active symptoms (see below) or previously inactive people who disregard advice to build up gradually. An additional list of contraindications is listed below [1,2].

Significant events are so rare that medical screening has the potential to be an unnecessary barrier to physical activity. Screening is most effective when focussed on active symptoms and co-morbidity [3].

It is fairly common for gyms to request a medical letter for people to use their facilities. Consider the option of providing a signed letter to overcome this barrier for individuals. Encouraging a slow start with gradual build up of activity (over 3 months or so) reduces the chances of poor outcomes.

This flow diagram will help you decide who might need referral for formal assessment before increasing their physical activity levels and may help address queries from gyms:

Notes

  1. Signs and symptoms, at rest or during activity; includes pain, discomfort in the chest, neck, jaw, arms, or other areas that may result from ischemia; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia; intermittent claudication; known heart murmur; or unusual fatigue or shortness of breath with usual activities

2. An easy way to explain the intensity of exercise is the talk test:

  • Moderate intensity: breathing rate is increased but you can still talk
  • Vigorous intensity: breathing rate is further increased and it is not possible to talk in full sentences

3. Patients with active symptoms or high risk necessitating medical screening will require formal investigations such as cardiac stress testing

Contraindications to physical activity include:

  • Unstable angina
  • Severe valvular stenosis or regurgitation
  • Active myocarditis or pericarditis
  • Ventricular tachycardia (uncontrolled)
  • Decompensated heart failure
  • Blood pressure >200/115 mmHg
  • Recent myocardial infarction (< six weeks)
  • Other clinical entities known to worsen during exercise
  • Acute Systemic infection

References

1) Fletcher GF, Ades PA, Kligfield P, et al. Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation. 2013;128(8):873-934.

2) Pedersen BK, Saltin B. Exercise as medicine – evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015;25 Suppl 3:1-72.

3) Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-7.

 

How do I know when to stop exercising?

Dizziness, sickness or excessive tiredness are signals to stop exercising and wait for symptoms to settle. Warning signs to seek urgent medical attention include blacking out, chest pain, or excessive shortness of breath.

Tips you may wish to share:

  • Encourage a slow, steady increase in activity to allow for adaptation to the new activity.
  • During the first 2-3 months of increasing physical activity it is sensible to be physically active with other people

I am worried about having a heart attack if I become more active

The risk of dying during exercise is very low[1][2]. The risk to health from being inactive far outweighs the risk of regular physical activity.

For the majority of people starting moderate intensity activity medical screening is not indicated. It is often an unnecessary barrier to physical activity.

Who has increased risk?

  • Habitually sedentary individuals may have unknown cardiovascular disease so should increase physical activity very gradually – suddenly doing vigorous intensity activity may increase risk of myocardial infarction in this inactive group by 100-fold5
  • Those with active symptoms such as chest pain, acute breathlessness, palpitations signs of heart failure may have serious underlying pathology and should be referred for specialist investigation5

Tips you may wish to share:

  • If starting physical activity for the first time build up very gradually over 3 months
  • Avoid sudden unaccustomed vigorous physical activity. Vigorous activity increases breathing to the level that it makes it hard to complete a sentence

References

Response:

The risk of dropping down dead from physical activity is very low [1,2]. The risk to health from being inactive far outweighs the risk of regular physical activity.

For the majority of people starting moderate intensity activity medical screening is not indicated. It is often an unnecessary barrier to physical activity.

Who has increased risk?

  • Habitually sedentary individuals may have unknown cardiovascular disease so should increase physical activity very gradually – suddenly doing vigorous intensity activity may increase risk of myocardial infarction in this inactive group by 100-fold [3]
  • Those with active symptoms such as chest pain, acute breathlessness, palpitations signs of heart failure may have serious underlying pathology and should be referred for specialist investigation5

Tips:

  1. If starting physical activity for the first time build up very gradually over 3 months.
  2. Avoid sudden unaccustomed vigorous physical activity. Vigorous activity makes you increase your breathing to the level that it makes it hard to complete a sentence.

References

  1. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.

  2. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.

  3. Thompson PD, Arena R, Riebe D, Pescatello LS, Medicine ACoS. ACSM’s new preparticipation health screening recommendations from ACSM’s guidelines for exercise testing and prescription, ninth edition. Curr Sports Med Rep. 2013;12(4):215-217.

3
Ask

“Has that helped?”

Did you know?

Start gently and build up slowly

The risk of death from physical activity is extremely low. For Men it is 1 death per 23 million hours and Women it is 1 death per 36.5 million hours.

  1. Albert CM, Mittleman MA, Chae CU, Lee IM, Hennekens CH, Manson JE. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med. 2000;343(19):1355-1361.
  2. Whang W, Manson JE, Hu FB, et al. Physical exertion, exercise, and sudden cardiac death in women. JAMA. 2006;295(12):1399-1403.

All physical activity counts towards moving more

“I don’t want to end up on insulin … if I can maintain this level of health I will be happy … I want to avoid even going on tablets”

Malpass A, Andrews R, Turner KM. Patients with type 2 diabetes experiences of making multiple lifestyle changes: a qualitative study. Patient Educ Couns 2009;74(2):258 – 63.