The guidelines are currently our best effort to promote the benefits of physical activity to patients, but which recommendations should patients follow when those recommendations differ?

This discordance among guidelines speaks to the lack of consensus among medical experts when it comes to precisely how much exercise we should get, and should be considered effective exercise for patients.

Maybe we shouldn't follow the American Heart Association, but rather the American Diabetes Association?

How many providers expect their patients to know how to reach 40-60% of their V(O)2 max for greater than ten minutes per session across three days to seven days for a total of 150 minutes per week? When was the last time your provider took your V(O)2 max?

That's why it can be difficult for patients and providers alike to successfully incorporate exercise into the treatment of a patient's chronic condition.

Let's take the example of a patient with diabetes mellitus type 2 (DM2) to see how the lack of clarity can translate to missed opportunities for tighter control. 

We know broadly exercise is good to reduce blood sugar levels, but how much exercise? And, what should be considered exercise in the first place? Is a walk around the park as beneficial as a five-minute kettlebell routine? What if the patient does aerobic exercise without resistance exercise? How do we know they get the same reduction in HgbA1c as the patients in published studies?

Current management of DM2 involves medications like metformin, insulin injections as needed, changes in diet and, of course, exercise prescription. In 2013, several large meta-analyses of exercise intervention in patients with diabetes showed exercise training for periods longer than eight weeks had a significant effect on reduction of HgbA1c levels despite variations in exercise programs. (The body's serum HgbA1c level is a marker for a patient's overall serum glucose levels over the past three months).

A HgbA1c reduction of 0.66% was found in the studies which compared exercise intervention patients with diabetes to matched controls, who were not involved in the exercise intervention. While that may sound insignificant, we know a 1% reduction in HgbA1c has been associated with 21% risk reduction of diabetic complications, which include microvascular disease like retinopathy or kidney disease, and macrovascular complications including stroke and heart attack. 

Importantly, the reduction in HgbA1c was independent of body weight changes, which indicates exercise can have beneficial effects for diabetic patients without any weight loss required (O’Hagan et. al. 2013). 

That's the good news about exercise and its benefits for patients with diabetes.

Quite often patients are expected by providers and managed-care plans to display a certain amount of self-care when it comes to exercise. Covering and planning effective exercise programs for individual patients requires time during rushed face-to-face evaluations that some doctors in offices and health care systems simply don't have. 

But how effective is self-care when most patients are left to pick their own exercise prescription?

While there are patients who are top performers in sports and masters at implementing their own work out routines, we know there are low rates of engagement in physical activity among patients with DM2. Large-scale national surveys of patients with diabetes show only 31% of self-reported respondents engage in sufficient physical activity to meet the minimum recommendations for exercise in the U.S. Surgeon General's report. 

Additionally, 38% of respondents report some physical activity but not enough to meet recommendations, and 31% report as inactive.This lack of activity occurs despite documented trends that diabetic patients receive more physical activity advice than other patients. 

So, 4 out of 5 patients with diabetes stand to benefit by decreasing their own HgbA1c by 1%  or more? Maybe we can start by getting absolutely clear on our guidance when it comes to exercise.

Download a free PDF of the Three Top Guidelines for Exercise Prescription in Treatment of DM2.