Prescribing Exercise for Patients with Type 2 Diabetes

Dr. Anderson:
We all know that exercise is a key component in maintaining a healthy lifestyle, but what special considerations are there for patients living with a chronic condition like Type 2 diabetes? That’s the exact question we’re going to be exploring today.

Welcome to Diabetes Discourse on ReachMD. I’m Dr. John Anderson, and joining me today to discuss exercise prescriptions for patients with diabetes is Dr. John Jakicic, Professor in the Department of Health and Physical Activity at the University of Pittsburgh. John, welcome to the program.

Dr. Jakicic:
Hi. Nice to have me.

Dr. Anderson:
John, tell us a little bit about your role at the University of Pittsburgh. What do you do up there?

Dr. Jakicic:
Well, I’m trained in exercise physiology and mostly work in the space of obesity and related chronic conditions, and that includes patients with Type 2 diabetes, cardiovascular disease and other things, but our research is really focused in on a couple of things. One has been to understand the dose of activity that’s probably necessary to move the needle on a variety of these factors, and then how also can we talk to patients about how they can actually become more physically active and build towards a lifestyle of physical activity and exercise, and that’s been our focus.

Dr. Anderson:
Great. You know, when we look at the American Diabetes Association’s standards of care, and we looked at algorithms, we always talk about lifestyle modifications being at the hallmark first part of treating Type 2 diabetes. What are the ADA standards of care for exercise in the patient with Type 2 diabetes? And what does the science tell us about the benefits of exercise?

Dr. Jakicic:
Yeah, the standards of care talk about physical activity and exercise. They kinda use some of those terms interchangeably. But it is a hallmark. It’s a key factor within this lifestyle paradigm. And what we know is that individuals who have Type 2 diabetes and start an active lifestyle and start an activity program, ultimately end up with much better diabetes control. We see people reducing medications, we see some people coming off of medications, depending on how well they’re doing. But it clearly gives a much better glucose regulation for sure. I think an important thing you mentioned, John, is this word “lifestyle.” You know, when we talk about this with our patients, and our study participants, we don’t just tell them what to do. We don’t say, “Here’s what you need to do. Go do it.” There’s a lot more to it, in terms of trying to work with them to figure out how does this fit within their lifestyle so it can become part of their lifestyle, and I think that’s a really critical component.

Dr. Anderson:
In general, we’re sitting down 15 minutes of time every three or four months with a patient. You know that, one, we don’t have the expertise – many of us – to be able to coach or to dig deep enough, but a one-on-one discussion with a patient really allows you more time, right? And it allows you a much deeper dive into their preferences, their barriers, that type of thing, doesn’t it?

Dr. Jakicic:
It sure does, and I think that last word you said there was very, very important, and that is “a deeper dive into the barriers,” because so many times, I’ve seen very quickly in clinical practice, you gotta go quick, you gotta go quick, you only have so much time. And it’s alright, Mr. or Mrs. Jones, go out, be physically active, it’s good for you – and that’s about all you can say. But I think that it’s critically important that you ask patients, “What’s getting in the way of you being physically active?” Because that partially will help us to think about how we can talk to them about physical activity. The barriers that are present now are the barriers that they will always be facing, and so we need to understand those in order to actually kind of make a good recommendation to them, so that they can move forward.

Dr. Anderson:
Yeah, much like we talk about individualizing prescription and medical therapy, it’s about individualizing the goals for exercise. How do you have those discussions with patients who really are not physically active at all and it’s time to at least make some incremental change?

Dr. Jakicic:
Yeah, I think that there’s some great opportunities right now, and I think it partially goes back to us starting to couch this discussion as not an exercise discussion, but as an activity discussion, and thinking about how we can start to, first and foremost, get individuals to get up off the couch, get up out of the chair, get up out of the bed, and start to move around a lot more. When we start to get that going, then we can start progressing to this kind of real prescription of what you and I talk about as exercise. But when somebody’s resistant to starting an exercise program, we can, a lot of times, make a lot of headway by talking about, “Let’s start to just get you a little bit more active during the day.” The first step is the hardest step. And if we can say, “Well, can you go outside and just walk up and down the block two or three times?” What we find is that when we make that kind of recommendation, it’s very doable. We find out they walk up and down the block ten times, not two or three times. So, beginning with “What can you do” as opposed to what the ultimate goal will be is a great place to start.

Dr. Anderson:
So for those just tuning in, you’re listening to Diabetes Discourse on ReachMD. I’m Dr. John Anderson, and today I’m speaking with Dr. John Jakicic about exercise prescriptions for patients with diabetes. So let’s talk now about something you said a lot about, which is actually making exercise prescriptions. And this is something we can do in primary care. Tell me what an exercise prescription is.

Dr. Jakicic:
Well, I guess it’s the same as what you would do in medicine. Being specific and laying out the very specific components of what it is to exercise. How frequently you want to do it, how much you should do, when you do it, how hard it should be, and very importantly, what you will do in order to make those goals. So, it’s kinda like when you write a prescription for medicine – how many pills do you take, how many days out of the week do you take it, how often on a daily basis do you take it – we think about exercise and activity basically the same way. And I think one really important way that I like to couch the discussion with patients, John, is: think about activity like you do brushing your teeth. It’s something you do every day. You don’t brush your teeth, hopefully, three days a week. You do something every day, and we want them to think about activity and exercise the same way.

Dr. Anderson:
John, frequently here, you know, patients who are wanting to start activity, and even progress to exercise, in the primary care world, but they’ve been so inactive for a while. I think a lot of primary care providers ask the question, “Do I need to do any sort of cardiac stress testing?” What patient might I need to sort out for something more before I actually have them implement a plan?

Dr. Jakicic:
So I think it depends on what the plan is, and I think it depends on the severity. But if someone has had a strong history of cardiovascular problems, you’re gonna want to be a little bit more cautious with them, just to make sure that they’re okay. But my philosophy on this, John, is, you know, for many patients, they get out of their car, they walk into their physician’s office that may be, you know, 100 feet, 200 feet. They walk back from the physician’s office back to their car, and nothing bad happens. And I sit here and say for that kind of patient, let’s just try to get them to do more of that. Let’s not overmedicalize it, but let’s just be careful. For people that are kind of at the high end of the risk spectrum, we wanna be a little bit more careful with them, just so that we’re not overdoing it and over-prescribing.

Dr. Anderson:
And John, when you’re dealing with patients who may be on agents that can produce hypoglycemia, whether that’s insulin or secretagogues, is it important for patients to understand the glycemic effect of exercise when they’re doing it?

Dr. Jakicic:
I think it absolutely is, and early on, for our patients, when we’ve had patients with diabetes that we’ve been working with and trying to get them to be more active, and a lot of that is home-based. So they’re not in our clinic doing this, a lot of times. We have them do a few things. We have them try to take a glucose reading before they go out and do their activity. We try to get ‘em to take a glucose reading when they’re done, so they visually can see what it’s doing for them. But at the same time, because that individual response can be so variable, we’re coaching them up on, you know, have this with you, or that with you, in the event that you start to feel a little bit hypoglycemic, and you’re half a mile away from your home, nothing bad’s gonna happen to you, but we find that to be a very powerful tool, that people go, “Wow. If I just did more of that, look what that’s going to do for me.” That’s gonna help, but we just gotta be careful we don’t overdo it.

Dr. Anderson:
You know, John, it’s interesting, because in this continuous glucose-monitoring world that we’re seeing some of our patients with new-onset, Type 2 diabetes, you’re seeing the exact same effect when they go, “Oh, wow – mac ‘n cheese. I had no idea.” Right? So, I think information for people is powerful, and I think understanding the improvement in glycemia with something as simple as a 20-minute walk is really critically important in terms of modifying behavior.

Dr. Jakicic:
I think it’s extremely important, and you have the continuous glucose monitors that many of your patients are probably using. We have a lot of people that are wearing various types of watches and bands and things that give them feedback on their activity. All this information is really important. I think our goal here should be, how do we help them to tie it all together? How do we make them connect the dots, so on a day that they see these steps, and they see this on their glucose monitor, it may attribute one to the other? That information is really powerful, if we can help them to do that.

Dr. Anderson:
You know, again, I think so much of us in both endocrinology and primary care, we look at that first part of the algorithm, and it goes, okay metformin. Right?

Dr. Jakicic:
Mm-hmm.

Dr. Anderson:
We completely skip the things that we’ve been talking about today. So, it’s important, I think, for our patients with Type 2 diabetes, where there are exercise specialists available, to try to hit this at the time of diagnosis, as you said, in an individually assessed way, and not just a “I need you to walk three miles a day, four days a week.”

Dr. Jakicic:
Yeah. I am thinking the more you individualize it, even if it feels the same to you, it needs to feel different to that person. It needs to feel like they’re listening to me, and this fits with where I am, what works in my lifestyle, my physician’s listening to me. I think that’s a critically important step when it comes to physical activity.

Dr. Anderson:
And I think it’s also that in primary care, we celebrate the little successes, right? If they’ve got done what they’ve wanted to, and they come back in three months and they’ve lost a pound, but they’re much more active, I think it’s our job to be their cheerleaders, isn’t it?

Dr. Jakicic:
It sure is, you know, I think the word of the physician and the health care provider goes so far with many patients. And you know, if they’ve worked really hard for two, three, six months – whatever it is between visits – they come back in and nobody says anything about it – that’s not very reinforcing. So pay attention to that and give ‘em a pat on the back when they deserve it.

Dr. Anderson:
Well, I promise you, my patients hold me accountable. If I walk in the room and they’ve lost ten pounds, and it’s not the first thing comes out of my mouth (laughter) They remind me!

Dr. Jakicic:
That’s great.

Dr. Anderson:
Well, that’s all the time we have for today, but I want to thank you, John, and this is Dr. John Jakicic, for joining us today to discuss exercise prescriptions in the field of diabetic care. John, it was great speaking with you today.

Dr. Jakicic:
Great, thanks for having me.

Dr. Anderson:
For ReachMD, I’m John Anderson. To access this episode, and others from Diabetes Discourse, visit reachmd.com/diabetesdiscourse, where you can Be Part of the Knowledge. Thanks for listening.