The Pages section of GPnotebook comprises more than 30,000 concise, interlinked clinical reference articles, each focused on a specific primary care topic.
There is no need to run into trouble when discussing exercise and type 2 diabetes, as the below case will hopefully show.
Pat is a Gaelic football fanatic who used to play for his county team and has been living with type 2 diabetes for the past 5 years. He is here for a chronic disease management visit today and is disappointed to learn that, unfortunately, his HbA1c has risen from 57 to 62 mmol/mol (7.4% to 7.8%), which is off target for him. He is 63 years old, has a raised QRISK, and is taking metformin, a sodium–glucose cotransporter 2 inhibitor, an angiotensin-converting-enzyme inhibitor and a statin. His blood pressure is controlled, and his lipids are on target. His BMI is 31 kg/m2.
I am about to start giving him information on glucagon-like peptide-1 (GLP-1) receptor agonists when he throws me a curveball…
“Not another medicine!” he exclaims. “Can’t we look at something else? My son Derek has just qualified as a personal trainer and he has offered to train me – with your blessing, Doc…”
I have to say that I am delighted to hear this, and not only because it avoids navigating the current GLP-1 receptor agonist shortage. It is great to put Pat in the driving seat with regard to his own care.
Handily, the GPnotebook page on exercise in the management of type 2 diabetes has recently been updated to reflect new data – so I can give him some good evidence-based information.
The important role of physical activity in reducing weight and increasing insulin sensitivity in type 2 diabetes is well known. But exercise and physical activity are broad terms, so it is great to be able to point patients to some of the specific benefits of different types of exercise.
For highly motivated individuals like Pat, a recent meta-analysis has shown that three 45-minute moderate-intensity aerobic workouts per week can reduce HbA1c concentrations to a degree sufficient to reduce the risk of myocardial infarction by 9% and microvascular complications by 24%.
The GPnotebook page on exercise in the management of type 2 diabetes also highlights some benefits of high-intensity interval training. This involves short bursts of high-intensity exercise interspersed with periods of recovery, and this kind of training has been shown to improve aerobic fitness and HbA1c in people diagnosed with type 2 diabetes.
Exercise programmes incorporating physical activity of >150 minutes per week have been associated with an HbA1c reduction of 0.89 percentage points (the corresponding reduction for programmes with <150 minutes per week was 0.36 percentage points). When such programmes are combined with positive dietary changes, the improvements can be greater still.
Many of our patients, however, won’t find the regimens mentioned above to be suitable – even Pat was a little intimidated. It is important, therefore, to be flexible in our recommendations about exercise, and to be prepared to take things down a notch. A brisk walk of a mile every day, for instance, will still confer some benefits. This HSE page is a great resource, with options on exercise for everyone.
Some heartening evidence has shown that older adults can benefit from resistance training. In research cited on the GPnotebook page on exercise in the management of type 2 diabetes, resistance training was found to be associated with a three-fold greater reduction in HbA1c in patients with type 2 diabetes aged 60–80 years compared with people in a non-exercising control group.
Physical activity also offers benefits for blood pressure control and is associated with a reduction in all-cause mortality.
There are very few of our patients with type 2 diabetes who would not benefit from exercise. However, caution is needed for people on medications that can cause hypoglycaemia (e.g. insulin or gliclazide). Reviewing the safety tips on this Diabetes UK page can be helpful here. A few other exceptions include people who are immediately post-myocardial infarction and those with acute foot ulceration. In cases like these, specialist advice on exercise will be needed.
In Pat’s case, it was great to fill him in on all the benefits of physical activity from the recently updated GPnotebook page and to signpost him to our fantastic local resources from the HSE. Advice on exercise specifically for people living with diabetes can be found here.
If you would like to read more about the benefits of exercise in other medical conditions, this GPnotebook page on exercise in osteoarthritis is really worth a look.
I also found this GPnotebook page – on an early suggestion that metformin may be related to reduced pancreatic cancer risk and improved outcomes in people with type 2 diabetes – to be fascinating.
I hope you enjoyed this month’s update, and I look forward to writing for you again next month.
Since 2001, GPnotebook has been a "go-to" clinical reference source for busy primary care professionals seeking quick answers to clinical queries
Written by practising GPs, GPnotebook comprises more than 30,000 pages of clinical reference material, with each article focused on a specific primary care topic
Information is organised into short, easy-to-read articles – quick enough to use during consultations. Hundreds of updates every month
As well as the written reference material, we have a growing library of video and podcast content, along with educational modules and quizzes to support learning and personal development