Physical Exercise & Activity

Exercise is a good idea for people with diabetes (as it is for people without diabetes) because it improves your general health.

You can exercise as often as you like, and participate in a wide variety of sports and activities. For some more dangerous sports, eg diving, you may need to take specialist advice.

A person without diabetes does not have hypos during exercise. Their body automatically reduces the amount of insulin released. This process does not occur in people who have diabetes treated with insulin. Also, increased activity of any sort will speed up the rate at which you use glucose, as it is burned up for energy. Therefore, it is important to plan ahead to prevent unnecessary hypos during your activity.

Exercise that is very much more than you are used to (either more vigorous or more prolonged) may keep your blood glucose low for up to 18hours afterwards. This is due to your body replacing the glucose it had stred in its muscle, which was used during the exercise. This does not just apply to sport. It also applies at other times of increased physical activity, eg spring cleaning, moving house, shopping, sex or gardening.

Things to consider when contemplating physical activity or exercise:

• Always carry rapid-acting CPs.
• Monitor blood glucose before ans after any physical activity or exercise.
• Give hypo treatment if blood glucose is below 3.5mmol/l before exercise.
• Consider the timing of when any insulin has been given.

Hypos can be prevented either by reducing your insulin or increasing your carbohydrate intake before, during and/or after the exercise.

Insulin Adjustment

It is not possible to give exact dose reductions. You need to determine the effect of exercise on your blood glucose by self-monitoring and adjusting your insulin dose.

Physical Exercise & Activity Guide

Setting Goals and Action Planning

Most people who come to a DAFNE course have something that they would like to be different about their life with diabetes. You will probably have your own individual reasons for attending.

DAFNE is all about change. There are new skills to be learned and practised and knowledge to be gained, but the long-term success of DAFNE depends upon how you fit DAFNE into your everyday life.

From research, we know that people are more likely to be successful when making changes, if they have set a realistic goal that it is important to them, followed by the development of an action plan, which states exactly how they are going to go abou achieving the long-term goal. Doing these two things seems to really help people to get where they want to be.

So throughout the DAFNE course you will have some time to develop your own plans each day, and at the end of the course you will have some time to set a goal that is important to you, and plan the small steps that will show you how you would like to go about reaching it.

How do I work out what my goals are?

You might be reading this and thinking 'I don't know what I want to be different?' You may have come on the DAFNE course because someone suggested it to you and you do not really have any particular expectations. This is absolutely fine and it might be that over the week you begin to think of things you would like to be different.

Sometimes it can help to think of goals as short and long term. Long-term goals are what you would like to achieve over the next few months or even years. Short-term goals are possibly the steps along the way to achieving your long-term goal or they can be some of the things that affect your life on a day to day basis. It is a bit like a set of steps; at the top is your long term goal with each step being a change you make along the way.

If you are struggling to think about a long term goal you could try to imagine your future self and future life. When you think about yourself and your life living with diabetes this time next year what do you see? What would you like to be different?

The difference in your future life might be your long-term goal. Remember, to choose something that is important to you.

What do I need to do to achieve my goal?

So there might be something that you would like to be different. It could be, for eample, that you want your blood glucose to be steadier, or you want to be able to exercise without risking severe hypos. With DAFNE we know that there are a set of things you need to do to achieve these goals.

We call these DAFNE behaviours or competencies - things you will need to learn and do. These include:

• Taking your BGs at the right time.
• Recording BGs in your diary.
• Counting the carbohydrate in your food/drinks.
• Spending time to look at and reflect on your diary in order to notice the patterns over time.
• Working out your insulin dose for each meal/snack.
• Taking your insulin.
• Making adjustments to your dose of insulin using the DAFNE principles.
• Experimenting a little and learning the impact of exercise, alcohol, food and travel.
• Getting used to your BGs being lower.
• Managing mild hypos.
• Getting used to not having bed time snacks to manage your BGs.
• Getting support to help you develop your DAFNE skills or when you are finding things difficult.

Fitting these DAFNE actions into your life are almost like the steps along the way to achieving your long-term goal.

So how do I make an Action Plan?
When it comes to making an action plan there are some things that we know from the research that it is useful to include or think about:

1. Be exact about what you are going to do. Try to describe as accurately as you can what it is you are going to do. For example rather than 'I will do more BG monitoring' you can be more exact and say 'I am going to do my BG tests before my breakfast, lunch, evening meal and bedtime'. This is an important strategy as you will know whether you have been able to put your plan in place.
2. Set plans that are realistic and that you can actually do. Make sure your plan is realistic and achievable for you. It helps people to grow in confidence if they have a success and then build on that rather than set their expectations too high and not get started. This does not mean that your targets can't be challenging, it can help if they are, but they need to be something you can achieve.
3. Think about the timing. It can also help to think about 'time' when making a plan. When will you start, when will you do what you are planning and when will you review how things are going. How often have you thought that you would really like to do something but months go by without actually having started? Or you start to make a change but over time find that you have not kept up your good intentions. Setting a review date or day to check how things are going can help with this.
4. Consider how confident you are? Confidence is most important when making changes. People are less likely to go away and do something if they feel that they will not be able to succeed. In DAFNE when you are making a plan we ask you to score your levels of confidence. A score of 1 means that you are not at all confident that you can make the change, 10 means you are very confident. It seems that people who score over 7 are more likely to go away and put their plan into place. If your confidence score is lower than 7 we may ask you to think about what might help you become more confident. Sometimes we might ask you to think about whether you have chosen to do something that is important enough for you and review whether it may help to start with a different goal.
5. Think about what will stop you? Finally looking at the barriers, the things that might get in the way and possibly thinking about how you may overcome these difficulties if they arise is also important.
6. Getting support. Getting the support you need when trying to achieve your goal is essential. Getting skilled and confident in DAFNE takes time and effort. People who get the support they need seem to fare better especially in the first year or so. You will be given some time to think about support when you are making your action plan. Some examples of support include: Ringing or visiting the DAFNE educator, talking to other DAFNE graduates, reading the support material provided by DAFNE, talking with family or friends, attending follow up sessions.

Keeping DAFNE going.
There is no rule as to how frequently you set yourself new goals and develop action plans. You might find that it is helpful to review 'where you are at' every now and again as some people find that they gradually move away from the DAFNE principles. This may be because other things in life have got in the way or that like most of us their good intentions fade over time. At times like this revisiting your long term goals and the steps you have taken to get there might be a good idea. Sometimes it is difficult to get back on track and it couls be that at times like these contacting your DAFNE educator for extra support may help. 

Annual Review

Regular follow-up at your diabetes clinic (at least once a year) is essential. Not only do these clinics detect any problems related to your diabetes and allow treatment to begin but, more importantly, they may prevent problems from occurring.

The following sections outline the main things that should be checked at your clinic at least annually, eplaining why they need to be checked and what may be done if problems are detected.

Glycated Haemoglobin (HbA1c)

A large American research study called "The Diabetes Control and Complications Trial" (DCCT), published in 1993, showed that maintaining good blood glucose levels delayed the onset of damage to the small blood vessels in the eyes, kidneys and nerves (micro-vascular complications) in people with Type 1 diabetes. There are no additional benefits of having an HbA1c level, which is too low (below 6.0%) as this has been found to increase the risk of severe hypos. We therefore recommend a target range of 6.0% to 7.0%. In order to check your own progress, it is worth getting your HbA1c measured every three months or so.

Eyes

It is important that you have your eyes examined by a doctor or optician at least once a year. This is done by having eye drops put into your eyes which dilates your pupils so that the back of your eye can be seen using a torch-like instrument called an 'opthalmoscope'. Sometimes this is done using a special camera that can take a photograph of the inside of your eye.

Poorly controlled diabetes increases the risk of damage to the blood vessels in the eye. This is called diabetic retinopathy. Permanent damage can occur if there is untreated bleeding from these vessels. In the early stages you may not be aware of these problems. Retinopathy can be treated by specialist eye doctors (opthalmologists) using laser therapy. Attending for your annual eye check could therefore save your sight.

Kidneys

Once a year, you will be asked to bring a urine sample to your clinic to check for protein. Ideally, this sample should be the first urine you pass in the morning. You will also have a blood sample taken to be tested for 'salts' and 'waste products' such as 'creatinine', which your kidneys should normally filter out of your blood into your urine.

Having poorly controlled diabetes may increase the risk of damage to the small blood vessels in the kidneys. This is called diabetic nephropathy. The first sign of diabetic nephropathy is the presence of a small amount of protein in the urine. This is called microalbuminuria. If you have signs of microalbuminuria, your doctor may prescribe a tablet known as an 'ACE inhibitor' (eg Ramipril, Perindopril, Captopril, Enalapril) as these have been found to prevent nephropathy getting worse. If untreated, nephropathy can eventually lead to kidney failure.

Nerves & Feet

At your diabetes clinic your feet will be examined by the doctor, nurse or chiropodist. As well as having the general condition of the skin and nails on your feet checked, your nerves will also be tested using a tuning fork, nylon filament or vibration meter.


Diabetic neuropathy is the name given to nerve damage resulting from diabetic microvascular disease. The risk of neuropathy is increased by poor diabetes control. Neuropathy particularly affects the feet. The symptoms of this include altered sensation, numbness or pain in your feet. If you think you may have neuropathy (or some of the symptoms), contact your doctor or chiropodist so that your feet can be checked amd regular chiropody treatment started if required.

Neuropathy also may affect male sexual function causing impotence. If you experience any problems with erections or sexual function, mention it to your doctor or nurse as there are medications and advice that can help.

Blood Pressure

It is important that your blood pressure remains close to normal levels, ie 130/80 or lower. High blood pressure (hypertension) can also affect your kidneys and eyes leading to further damage. If your blood pressure is high, your blood vessels are under increased pressure. If left untreated over a long period of time, it can also lead to damage to the heart and large blood vessels, increasing your chances of heart attack or stroke.

If your blood pressure is too high, you may be prescribed tablets and given dietary advice to help lower it. There are many different types of blood pressure lowering tablets that may be used, but one type, called 'ACE inhibitors' (eg Ramipril, Perindopril, Captopril, Enalapril), seem to be particularly useful in protecting your kidneys and heart.

By lowering your salt intake in your diet you may help to reduce your blood pressure. You can lower your salt intake by:

• Not eating too many salty snacks (eg crisps and nuts).
• Not adding salt to your cooking (eg use herbs and spices to flavour food).
• Avoid adding salt to your food at the table.

You can also help to reduce your blood pressure if you:

• Increase your levels of physical activity.
• Lose some weight (if you are overweight).
• Stop smoking (if you smoke).
• Cut down your alcohol intake.

Blood Fats (Lipids) & Cholesterol

Blood is taken to test the level of fats (lipids) at the same time blood is drawn for all the other tests required for the Annual Review. Occasionally your doctor may ask you to attend clinic 'fasting' for this particular test.

Arteriosclerosis (hardening of the arteries) can also occur in people with Type 1 diabetes. The level of fats in a 'fasting' sample of your blood gives an indication of your risk for developing arteriosclerosis and heart disease.

Normal ranges for lipids:

Total Cholesterol: below 5mmol/l

High Density Lipoprotein (HDL): over 1.1mmol/l

Low Density Lipoprotein (LDL): below 3mmol/l

Triglycerides: below 2.3mmol/l

Total cholesterol/HDL ratio: below 4

HDL has a protective effect, while LDL and Triglycerides have a damaging effect and may increase your risk of developing heart disease. Your lipid levels can sometimes be raisedd due to genetic (inherited) reasons. However, making different food choices can help. Physical activity can also increase HDL levels as well as promote a healthy body weight, which also has a beneficial effect on the heart.

Food choices should include:

• One portion of oily fish per week (salmon, mackerel, herring, kippers and sardines).
• Fruit and vegetables.
• Monounsaturated fat (olive oil, rapeseed oil) instead of saturated fat (butter, biscuits, cakes, pastry, cheese and fatty meat).

Medication, such as 'statins' (eg Simvastatin, Atorvastatin) or 'fibrates', may be prescribed by your doctor, you can discuss this with your diabetes team.

Smoking

Your doctor or nurse should, as part of your annual review, ask you if you smoke.

Smoking can have a damaging effect on the blood vessels. It is even more important for someone with diabetes to give up smoking than for someone without diabetes, because smoking further increases the risk of poor circulation. There are many ways to do this including nicotine replacement, tablets and self-help groups that can make it easier to quit. If you would like further information about quitting smoking you can speak to your pharmacist, GP, practice nurse or a member of your diabetes team.

The NHS Smokefree service can offer help in quitting smoking. They can be contacted on 0800 022 4 332 or online at www.smokefree.nhs.uk

Weight

Your weight (and height) will be checked at your diabetic clinic appointment.

Maintaining a healthy weight for your height is important in reducing your risks of developing heart disease and some types of cancers. Your dietitian will be able to offer further advice if required.

Footcare

You may have heard of people with diabetes having problems with their feet. Understanding basic foor care will help you to reduce the risk of long-term problems.

The blood supply and sensation in your feet need to be checked every year as part of your annual review. The main problems are numbness or loss of sensation and/or poor circulation of the blood to your feet. If these are not recognised this could lead to you injuring your foot without realising it and poor wound healing with an increased risk of infection.

The following are recommended as good foot care practise:

• Check your feet daily, making sure the skin is not sore or broken.
• Use a moisturiser on dry skin and keep your feet clean by washing and drying daily.
• Wear well-fitting shoes.
• Cut your nails to the shape of the toe (not straight across), and file any rough edges.
• Give up smoking, as smoking increases the risk of poor circulation, particularly to your feet.

If you have been told that you have neuropathy (loss of sensation), this means you could injure your feet without feeling any discomfort. It is important not to go barefoot or walk on any very hot or very cold surface, eg a hot beach, radiators, hot water bottles, hot bath water or hot bath taps, without protection.

If you have any problems, it is important that you contact your GP or make an appointment with a chiropodist/podiatrist.

Travel

When planning to travel you will need to consider the extra supplies that you may need and the timing of your trip. This is especially important if you are passing through different time zones. The following will be useful:

• Make sure you have medical travel insurance and that your diabetes is covered on this policy.
• If possible, be aware of local medical facilities.
• Check if special vaccinations are necessary - these are available through your GP.
• Check before you go that U100 insulin is available in the country you are visiting.

Always carry the following with you (these items will need to be carried in your hand luggage if flying):

• Adequate supplies of insulin and syringes or pen needles.
• A spare pen-injection device (if you use these).
• Blood testing equipment.
• Glucagon kit.
• Ketone testing strips.
• Safe clip (for safe disposal of needles).
• Rapid-acting carbohydrate.
• Medicine for minor illness, and for travel sickness if required.
• Identification (ie a card or jewellery identifying you as diabetic in the local language).
• Extra food in case of delays.

During travel, keep your insulin around room temperature or just below, but above freeing point. Please be aware that insulin can freeze if stored in the hold of an aircraft.

Give a small supply of insulin and a syringe/pen-injector to someone you are travelling with, in case your luggage is lost or delayed.

Different Time Zones
When travelling east to west your day will be lengthened. If there is a difference of several hours, you will probably eat at least one extra meal and this will require extra quick-acting insulin. Take your long-acting insulin at your destination as normal.

When travelling west to east your day will be shortened. Consider the time between doses of background insulin to avoid any excessive overlap.

Driving

If your diabetes is treated by insulin, and you wish to drive, it is your legal responsibility to inform the DVLA and your insurance company.

Usually your licence will be renewed every three years providing you have no complications of diabetes that may make it unsafe for you to drive eg problems with your eyes or circulation.

Inability to recognise your own hypo warning signs also puts you and other road users at risk. You must not drive until your hypoglycaemia awareness returns.

There are restrictions on both heavy goods (over 3.5tonnes) abd passenger vehicle licenses (including taxi driving). It is important that you discuss these individually with the authority that grants those licences.

You need to carry rapid-acting carbohydrate in the car at all times. You must always test your blood glucose before driving, especially when you are making adjustments to your insulin doses during and following the DAFNE course. It is recommended that you do not commence driving unless your blood glucose level is over 5mmol/l (over 7mmol/l if you have reduced hypo awareness), Being hypoglycaemic at the wheel is classed as driving under the influence of drugs.

On long drives, stop and test blood glucose at regular intervals. You must never drive whilst having a hypo as your concentration and reactions will not be as good as usual.

If you feel a hypo:

• Pull over and stop the car.
• Remove the keys from the ignition and move into a passenger seat NB If you are sitting in the driver's seat, the police can charge you with being in control of a vehicle whilst under the influence of a drug.
• Treat the hypo.
• Do not continue to drive until the symptoms are completely resolved. Ideally, recheck your blood glucose to ensure it is above 5mmol/l.

Be aware that your brain function does not return to normal as quickly as your blood glucose, therefore you should not drive for at least 45minutes following a hypo. Make sure you are able to do simple mental tests before you start driving again, eg recalling your telephone number.

RELATED TOPICS: Hypoglycaemia, Loss of warning signs.

Contraception

It is important for women with diabetes to avoid unplanned pregnancies, for the reasons given above. Therefore reliable contraception needs to be used.

All types of available contraception are as suitable for women with diabetes as for those women without diabetes. If you would like further information, you should speak to your doctor or diabetes nurse at your diabeted clinic.

RELATED POSTS: Metabolic control

Pregnancy

Women with diabetes can have children. However, medical evidence shows an increased risk of complications for mother and baby when the mother has diabetes. Evidence also shows that this risk is minimised by normalising blood glucose before conception and throughout the pregnancy. You can continue to use your DAFNE skills throughout the pregnancy; in fact most women have found pregnancy and the insulin adjustments much easier to manage following DAFNE.

Planning a pregnancy will help reduce the risk of problems. Continue to use a reliable form of contraception (see below) until you have got your HbA1c as good as possible (6%-7%). Folic Acid id recommended for all women planning pregnancy - see your GP for a prescription and start this as soon as possible (you should continue taing this until 12 weeks into pregnancy).

The normal level of HbA1c is lower during pregnancy so we encourage women to try to get their HbA1c below 7% if possible. During pregnancy is one of the few times we recommend testing your blood sugar level in between meals. The target levels during pregnancy are:

• Less than 6mmol/l before meals.
• Less than 8mmol/l 1-2 hours after meals/before bed.

Blood glucose levels and insulin requirements change significantly during the stages of pregnancy. Most commonly, during the first few weeks you may experience more frequent hypoglycaemia, sometimes with a reduction in symptoms, or even severe hypos (see Severe hypoglycaemia), therefore it is useful for your partner to know how to help you to treat your hypos. You may also need to be more cautious about driving and test/record you blood glucose before getting into the car to drive. You may be advised to avoid driving temporarily if you have lost your hypo warnings.

In the latter stages of pregnancy (from around 26 weeks), insulin requirements usually increase. Follow the DAFNE guidelines for increasing your insulin doses and do not be surprised if you find your Background Insulin and/or Quick Acting : CP ratios are more than doubled by the end of your pregnancy.

Immediately after delivery of the baby, insulin doses return to pre-pregnancy (so it is useful to keep a record of what these were prior to pregnancy) and may need to be reduced further if you choose to breast-feed your baby; the guidelines for exercise can be a useful starting point for this.

Your doctor of diabetes nurse will be happy to discuss the local diabetes antenatal service and recommendations with you.

NovoRapid Insulin Dose Calculator

On the right you can find a link to my NovoRapid Dose Calculator, enter the amount of carbs you're about to eat (in grams) in the first yellow box, then your blood sugar reading (in mmol/l) in the second box and the spreadsheet will calculate approximately how much fast-acting insulin you need for the food you're eating...