Disclaimer: The following guide is my best guess on what content will be on the exam. I do not know what exactly will be on the exam but I have helped over a thousand health care professionals pass the exam.

Chapter 10- Physical Activity and Diabetes
Importance: Very High- Be very familiar with chapter
Approximate time recommended: 105 min

I have highlighted what I think will be important for the exam. However you should read the entire chapter. All areas in grey (key messages and recommendations) are also important for the exam.

Under the heading of:  Types of Exercise

Know the differences between aerobic exercise, resistance exercise and flexibility exercise

Under the heading of:  Benefits of Physical Activity

Be familiar with the benefits of physical activity. Generally you do not need to know about the individual studies on exercise as I haven’t seen any questions on the exam on them. Memorize the 150 minutes per week recommendation.

Under the heading of: Minimizing Risk of Exercise-Related Adverse Events

Be familiar with the recommendations for retinopathy, peripheral neuropathy, and when to recommend an ECG.

Be familiar with which patients are at higher risk of heat related illness and the recommendations on how they can minimize the risk of heat-related illness.

Be familiar with the how to minimize exercise induced hypoglycemia. Be familiar with the insulin reductions on pg S57. See the charts on pg 187 or pg 189 of chapter 20 of Understand your Diabetes which I have uploaded below

Here is a clearer copy of table which has been adapted from Hayes C. J Am Diet Assoc 97 (suppl 2): S167-S171.

Duration of Exercise	Blood Glucose	Additional Carbohydrates
Short duration (<30min) at light intensity	<5.0	10-15 grams
	>5.0	Not necessary
Moderate duration (30-60 min) at medium intensity	<5.0	30-45 grams
	5.0-9.9	15 grams for every 30 min of exercise
	10.0-13.9+	Not necessary
Longer duration (>60 min) at high intensity	<5.0	45 grams
	5.0-9.9	30-45 grams
	>9.9	15 grams per hour

 

Frequent Question: Why does high intensity sugars increase sugars? Shouldn’t all exercise decrease sugars?
High intensity exercise causes the muscles to significantly increase their glucose demand for peak performance. Think powerlifting, sprinting or boxing where if your muscles are weak due to lack of glucose, you are probably going to get hurt badly. In response to this high demand, the body floods the blood with glucose which temporarily raises glucose until the high intensity exercise brings the sugars down. Compare that intensity to a moderate jog. There is no significant demand so blood sugars just slowly go down.

Be familiar with the difference between type 1 and type 2 diabetes when minimizing risks related hyperglycemia as they are quite different.

Under the heading of: Reduction of Sedentary Behaviour

Any physical activity that you can encourage your patients to do is a win for your patient and you. The following are some practical tips that I have found to work well with patients (not on the exam so you can skip if needed):

Step 1- Start with small goals that work with the patient. If your patient hates gyms don’t recommend gyms. One of my patient’s goal is to walk to the mailbox and back after lunch. Eventually we got it to three back and forth walks to the mailbox back five times a week. I consider this a huge win as the guidelines state that reducing sedentary activity with light walking or resistance exercise can reduce post prandial sugars and triglycerides.

Step 2- Suggest the Diabetes Canada resistance band exercise routine. The video can can be found below:

Step 3- The PDF which can be printed out for your patients can be found below. I usually demonstrate the first couple of exercises with the patient so I can check if the patient’s form matches the video.

If you go this route I would suggest getting the patients to do a PAR-Q which can be found here: https://eparmedx.com/ to ensure that they are ready for physical activity.

Step 4- You can buy bulk 50-yard resistance/Thera bands cheaply from Amazon. Typically they are ~$50 and sometimes cheaper if you can find them on sale. I cut a yard of resistance band for patients who are interested.  This motivates patients to take your advice and starts to build a relationship with a small $1 gift.

Parks Canada has a program where you can sign patients up for a free park pass! Encourage your patients to visit a park for exercise to boost their physical health and connect with nature to boost their mental health. Please see https://www.parkprescriptions.ca/ for details and sign yourself up as a pharmacist/prescriber and then sign patients up for a free park pass!

Under the heading of: The Use of Adjunct Motivational Interventions to Improve Physical Activity Uptake

Be familiar with how you can use motivation interviewing or motivational communication to facilitate behaviour change.  If you need a review of the above please the summary below.

 

I also feel this is a good video to review motivational interviewing.

 

Under the heading of: Objective Monitoring of Physical Activity

Be familiar with Table 2 and Table 3

Also be familiar with the following handout:

Practice Questions (press show answer to reveal answer)

A 40 year old male patient who has recently been diagnosed with type 2 diabetes wants to start low intensity walking for exercise. His A1c is 6.6% (0.66) and he is not on any medications. He has does not have a history of cardiovascular disease. Which one of the following recommendations should you not recommend?

A) Encourage a goal of 150 minutes of exercise per week
B) Recommend getting medical clearance from a medical doctor before starting
C) Also recommend resistance band exercises as adding resistance exercises has an additive effect
D) Suggest using a pedometer to track his number of steps

You have a 80 year old female patient with long standing type 1 diabetes. She comes in summer for a follow up appointment with you. She plans to start low intensity walking for exercise. Her A1c is 8.0% (0.08) and she is on Novorapid (aspart) three times daily with meals and Lantus (glargine) once daily. She had a stroke last year and also has osteoporosis and low vitamin D levels. Which one of the following recommendations should you not recommend?

A) Encourage a goal of 150 minutes of exercise per week
B) Recommend getting medical clearance from a medical doctor before starting
C) Walk outside around noon in the summer to get enough sunlight for vitamin D production
D) Take 15 grams of carbohydrate before starting to walk to prevent hypoglycemia

You have a 20 year old male patient with type 1 diabetes who is a competitive athlete. He uses an insulin pump and currently is using 1.5 units per hour of Huamlog (lispro) as a basal dose. His insulin to carbohydrate ratio is 1:10 and his insulin sensitivity factor is 1:2. He calls you right before he starts to run a highly competitive 4 hour marathon. His current blood sugar is 6.5 mmol/L.  Which one of the following recommendations would not help him prevent hypoglycemia during his marathon?

A) Reduce his basal insulin rate to 0.5 units per hour until he finishes the marathon and is able to test
B) Consume 30-45 grams of carbohydrate preferably in the form of a sports drink
C) Reduce his insulin to carbohydrate ratio to 1:15 and his insulin sensitivity factor to 1:3
D) Consume sports drinks that have carbohydrate while cycling

This ends the free portion of the Study Guide. If you would like to continue please purchase Package D or Package E.