Dr. V Mohan, as part of this exclusive 12-article series on Diabetes, answers questions posted by readers on the previous article- Exercise and Diabetes.

Question 1: With increase in exercise, can the dosage of anti-diabetic medicatons be decreased?

Dr. V Mohan: Yes, definitely. Although it also depends on the level of the exercise. A gentle stroll in the park for 20 to 30 minutes may not help reduce the dose of anti-diabetic drugs, but if the intensity of the exercise is increased and it leads to weight loss, the dose of anti-diabetic drugs can definitely be reduced. From my experience, I remember a type 1 diabetes patient (female) who was in college at the time. She suddenly started a vigorous exercise and dance program and developed severe low sugar reactions because the dose of insulin was not reduced.

So whenever severe exercise is being planned, more frequent blood sugar testing or even continuous glucose monitoring can be done and the dose of medicines be reduced if necessary.

---

Question 2: Is it necessary to give glargine only at night? Can it be given in the morning too? Can we combine glargine with premix insulin or can it only be given with regular insulin?

Dr. V Mohan: Glargine can be given at any time, either in the morning or night. Traditionally, it is given at bedtime, so that it covers the whole night and a good part of the day. However, for some patients who have high evening sugar, it may be better to give it in the morning.

Glargine as such cannot be combined with any insulin as it has an acidic pH and therefore it has to be given separately. As for the query on additional insulin regimens, they can be given along with glargine; any insulin regimen can be given. The most usual one is to add a regular insulin, once a day in which case it is called as ‘basal plus regimen’. If regular insulins are given 3 times a day, it is called as ‘basal bolus regimen’.

Although it is not conventional to combine a premix insulin with glargine, there is no harm in doing it. The premix can be given in the morning to cover the breakfast and lunch and even upto evening, and then glargine can be given at bedtime to cover the night and early morning. This is a slightly unconventional regimen, but in practice it works quite well.

---

Question 3: After exercising, my patient complains of severe muscular cramps and intense body ache. No response to L-carnitine. He is a diabetic with reasonable control of his blood sugar. What is your advice?

Dr. V Mohan: We will have to rule out whether the patient has any other deficiency. However, if ‘warming up’ and ‘cooling down’ exercises are done, and the intensity is built up gradually, there will be no cramps or body aches. Stretches will also help and these can be done either before or after the exercise. If these measures also don’t help, then additional investigations may be needed. Electrolytes will have to be checked to ensure that there is no problem with sodium or potassium levels.

---

Question 4: If a person has HBA1C between 6 and 7, FBS- 140, and PPBS-170 (average for one year), should he be prescribed medicine?

Dr. V Mohan: If the fasting blood sugar is more than 126 mg, then the person does have diabetes. Postprandial blood sugar is not used for diagnosis. An OGTT with a 2-hour plasma glucose sample would be ideal in this situation and if it is >200mg the patient has diabetes; if it is between 140 to 199, it is impaired glucose tolerance or prediabetes. HbA1c is less useful as a diagnostic test, but according to the American Diabetes Association, if it is more than 6.5%, it confirms diagnosis of diabetes. In your patient, if HbA1c is 7% and the FBS is 140 mg/dl; then clearly the patient has diabetes.

---

Question 5: Please guide on an exercise routine for people restricted by post-operative and muscle tear restrictions.

Dr. V Mohan: It is better to ask the surgeon about this as it depends on what surgery was done. Normally, a gentle walk should be fine, even in these situations.

---

Question 6: How much D-protein supplement support is needed in diabetic patients? 

Dr. V Mohan: There is no fixed amount for a protein supplement. It depends on whether the person is underweight and has evidence of malnutrition in which case, thrice a day protein supplement may be needed. Otherwise, once a day should be sufficient. Protein can be obtained easily from the diet itself in the case of non-vegetarians. In the case of vegetarians, it is a little more difficult and supplements may be needed.

---

Question 7: How should a person on insulin but no other complications plan his/her exercise? Is playing sports okay?

Dr. V Mohan: I think a person on insulin can take part in all exercises and games especially if he/she has no complications. However, as the intensity of the exercise increases, appropriate adjustment of insulin dosage may be needed.

---

Question 8: What should the exercise duration be to reduce metabolic inflammation?

Dr. V Mohan: The ideal time for exercise varies from patient to patient depending on one’s age and health condition especially the heart condition. On an average, atleast 30 minutes of brisk walk is recommended and if weight loss is the target, then the exercise should be increased to 45 minutes to one hour.

---

Question 9: How much time should a patient ideally devote for Yoga and Dhyana? Can it compensate for exercise routine?

Dr. V Mohan: Many patients with diabetes have stress-induced diabetes and if it is due to stress, anxiety, or depression, in such patients, we can expect good results with yoga, pranayama, and meditation. With respect to yogasanas, there are specific ones which are believed to help control diabetes and obviously they can be tried.

Pranayama is extremely useful to reduce stress and blood pressure and I would recommend it strongly for everyone. Dhyana is more difficult, but with practice it can make a person more focussed, improve the concentration levels and also help to control diabetes and blood pressure and help people be calmer and achieve better quality sleep.

---

Question 10: For someone who has diabetic complications, what sort of exercises and how much exercise would you recommend?

Dr. V Mohan: If one has proliferative diabetic retinopathy, the chances of a retinal bleed are high and hence, one should avoid lifting heavy weights or doing very strenuous or rigorous forms of exercise. Similarly, if one has had a stroke or heart attack, it is better to reduce the intensity of the exercise. However, some amount of exercise is still good even for such people. If one has neuropathy, one should use proper footwear to offload the pressure under the feet and to prevent foot ulcers. If one has diabetes-related complications in specific areas, such as periarthritis of the shoulder, then specific exercises for these would be indicated.

---

To read articles published in the series, click,

Treatment algorithm; factors to consider while prescribing medication: Dr. V Mohan

Diabetes Q&A with Dr. V Mohan: Treatment algorithm for DM

Managing hypertension in diabetic patients: Dr. V Mohan

Diabetes Q&A with Dr. V Mohan: Managing hypertension in diabetic patients

Diet and Diabetes: Dr. V Mohan

Exercise & Diabetes by Dr. V Mohan

Being a part of this exclusive series allows you to post a question for Dr. V Mohan. Answers will be published in the next article in this monthly series.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. V Mohan is the Chairman & Chief of Diabetology at Dr. Mohan’s Diabetes Specialities Centre & Madras Diabetes Research Foundation, Chennai, India.