# Exercise as it relates to Disease/Exercise for Type 2 Diabetes Mellitus in Indigenous Australians
## Diabetes Mellitus Type II

Diabetes Mellitus Type II or non insulin dependent diabetes mellitus (NIDDM) is a metabolic disease in which an elevated blood glucose level occurs, causing vascular complications and neuropathies. When food is ingested it is transformed into glucose, which is absorbed into the blood to be moved into cells and used by the body to provide energy. Glucose requires the hormone insulin to move into cells. The body maintains a stable blood glucose level by regulating insulin production by the pancreas. In diabetes mellitus type II, the amount of insulin produced varies but the function is impaired by insulin resistance, forcing the pancreas to work harder and produce more insulin. However, the amount of insulin available is insufficient for cells to uptake enough glucose to lower or maintain blood glucose levels. The exact cause of type 2 diabetes is unknown, however it is believed to be caused by both genetic and environmental factors.

### Risk Factors

* Family history of diabetes
* Increasing age (over 40 years of age)
* Obesity or a body mass index (BMI) greater than 25
* Physical inactivity
* Poor diet
* A history of glucose intolerance or elevated blood glucose
* Smoking
* Hypertension (high blood pressure)
* Metabolic syndrome: a collection of conditions that increase the risk for developing chronic lifestyle diseases
* Ethnicity: particularly those of Indigenous decent

## Diabetes in Indigenous Australians

Type II diabetes is more prevalent in Indigenous Australians than non Indigenous Australians with Aboriginal people three times more likely to have the chronic disease. This increased risk of disease is a result of:
* The influence of historical and political events
* Low socio-economic status
* Reduced education level
* Strong genetic predisposition
* Decreased use of health services due to rural location or culturally inappropriate healthcare
Indigenous people’s traditional lifestyles have changed due to urbanization and a shift to a western way of living. In Aboriginal communities they are now less likely to hunt and gather their bush tucker, therefore they are less physically active and their food is less likely to be from fresh healthy sources. Consequently, this further increases the risk for Indigenous Australians developing type II diabetes.

## Treatment/Management

Treatment of diabetes mellitus type II is designed to maintain a stable blood glucose level within normal parameters, between 4-6 mmol/L fasting, as this will prevent progression of the disease and complications from developing. There is no cure for type II diabetes but it can be controlled by medication and healthy lifestyle changes through diet and exercise.

### Medication

Type II diabetes medication increases insulin secretion, prevents the breakdown of glycogen to glucose so blood glucose levels are lowered and increases the body’s sensitivity to insulin allowing glucose to be taken up by cells.

### Diet

For people with diabetes the amount of food eaten should be balanced with the amount of fuel burned. A balanced healthy diet, keeping food intake to moderate levels is sufficient for people with type II diabetes to control blood glucose levels ensuring they do not become severely elevated. This can also indirectly result in weight loss and decrease the effects of obesity on diabetes.

## Exercise for Type II Diabetes

Indigenous people are becoming more sedentary and are engaging in physical activity less, resulting in diabetes and other chronic lifestyle diseases. Aboriginal people are also more likely to be overweight or obese due to physical inactivity and poor diet, worsening the insulin resistance evident in type II diabetes. Type II diabetes in Indigenous Australians can be prevented and managed, with a reduction in diabetes related complications, through exercise.
Exercise regulates glucose in the body by enhancing the action of insulin and allowing more glucose to be taken into cells to be used for energy. In the body insulin causes the glucose transporter protein 4 (GLUT 4) to move to the plasma membrane so glucose can move from the bloodstream into the muscle through these transporters. During exercise, skeletal muscle contracts, causing the translocation of GLUT 4 to the membrane without the need for insulin. In addition, exercise improves the insulin signaling pathway in skeletal muscles. These factors reduce blood glucose levels in the body, improves glucose sensitivity and reduces the need for medication. Regular exercise may also prevent type II diabetes from developing. Exercise also reduces body fat-increasing insulin sensitivity, and reduces the risk of cardiovascular events associated with diabetes.
Although medication tends to be the typical treatment for diabetes, exercise is a vital aspect of the treatment plan because of its effects on glucose uptake independent of insulin and the resultant increased insulin sensitivity. Evidence suggests both aerobic exercise and resistance training have a positive impact on health status and control of type II diabetes blood glucose levels.
Before engaging in an exercise program, an individual with diabetes should complete a physical activity prescreening tool and undergo a health check with a professional. Overall medical/health status, medication, and associated co morbidities, as well as baseline cardiovascular fitness, strength and flexibility should be considered in designing an exercise program for type II diabetics.
CAUTION: In people with diabetes, exercise may induce a hypoglycemic event (low glucose levels), which means the body cannot function effectively. Meal timing and consuming a carbohydrate snack before, during or post exercise will prevent this from occurring.

### Physical Activity Guidelines

AEROBIC EXERCISE: repeated continuous low intensity movements of the same muscle groups. Including walking, running, swimming, cycling, team sports and dance.
| Frequency | 3–7 days per week |
| Intensity | 50%-80% of VO2 or HRR, RPE of 12-16/20 |
| Time | 20–60 minutes of continuous or accumulated in bouts moderate physical activity per day. Total of 150 minutes per week |
| Type | Activities that use large muscle groups in a rhythmic continuous aerobic manner |
RESISTANCE TRAINING: performing muscular strength effort activities against a resistive force. Including body weight, resistance bands, free weights and machine weights.
| Frequency | 2–3 days per week. 48 hours rest between sessions |
| Intensity | 2-3 sets of 8-12 repetitions at 60%-80% 1 RM |
| Time | 8-10 exercises |
| Type | Whole body compound exercises using all major muscle groups or split sessions using selected muscle groups |

### Exercise for Indigenous Australians

Indigenous Australians face social and cultural barriers to physical activity participation. Time spent exercising alone is viewed as shameful, reducing the time for family and community. There is also limited access to conventional forms of exercise facilities for Indigenous people. There are insufficient culturally meaningful forms of exercise available for Aboriginal people and a lack of culturally appropriate information and services that focus on an Indigenous holistic view of health. Research indicates that culturally relevant and popular activities like sport are effective at promoting daily exercise in this group. Culturally, exercise is more meaningful to Indigenous Australians in a community setting with a focus on staying healthy for the whole family. Traditional games and dances should also be incorporated into education programs in schools and also to exercise plans. These strategies will enhance physical activity in Indigenous Australians assisting in the prevention and management of type II diabetes.

## Further reading

General Diabetes Information
Diabetes in Indigenous Australians
Physical Activity and Chronic Diseases in Indigenous Australians

## References

* 1 2 3 4 5 6 7 8 Diabetes Australia. (2014). Living with Diabetes. Accessed from www.diabetesaustralia.com.au
* 1 2 3 4 5 6 Guven, S., Matfin, G., & Kuenzi, J. (2009). Daibetes Mellitus and the Metabolic Sydrome. In Porth, C. & Matfin, G. Pathophysiology: Concepts of Altered Health States. 8th edn. Chapter 42. Philadelphia: Wolters Kluwer Health/ Lippincott Williams and Wilkins.
* 1 2 3 4 5 6 7 8 Sanchez, P. (2011). Nursing Care of Clients With Diabetes Mellitus. In Burke, K. (Ed.)., & Lemone, P. (Ed.). Medical Surgical Nursing: Critical Thinking in Client Care. Volume 1. Chapter 20. New South Wales, Australia: Pearson.
* 1 2 3 4 5 6 Minges, K., Zimmet, P., Magliano, D., Dunstan, D., Brown, A., & Shaw, J. (2011). Diabetes prevalence and determinants in Indigenous Australian Populations: A systemic review. Diabetes Research and Clinical Practice, 93 (2), 139-149.
* 1 2 3 4 5 6 Diabetes Australia. (2013). Aboriginal and Torres Strait Islander Diabetes Action Plan. Australian Government Department of Health and Aging. Accessed from http://www.diabetesaustralia.com.au/Documents/DA/Media%20Releases/Aboriginal%20and%20Torres%20Strait%20Islanders%20and%20Diabetes%20Action%20Plan.pdf
* 1 2 3 Maple-Brown, L., Cunningham, J., Dunne, K., Whitbread, C., Howard, D., Weeramanthri, T., Tatipata, S., Dunbar, T., Harper, C., Taylor, H., Zimmet, P., O’Dea, K., & Shaw, J. (2008). Complications of diabetes in urban Indigenous Australians: the DRUID study. Diabetes Research and Clinical Practice, 80 (3), 455-462.
* 1 2 3 4 5 6 7 8 Thomspson, W., Gordon, N. & Pescatello, L. (Eds.). (2010). ACSM’s Guidelines for Exercise Testing and Prescription. 8th Edition. United States of America: Wolters Kluwer Health.
* 1 2 3 4 5 Gray, C., Macniven, R. & Thomson, N. (2013). Review of physical activity among Indigenous people. Retrieved from http://www.healthinfonet.ecu.edu.au/health-risks/physical-activity/reviews/our-review
* 1 2 3 4 5 Jorge, M., Neves de Oliveria, V., Resende, N., Paraiso, L., Calixto, A., Diniz, A., & Geloneze, B. (2011). The effects of aerobic, resistance, and combined exercise on metabolic control, inflammatory markers, adipocytokines, and muscle insulin signaling in patients with type 2 diabetes mellitus. Metabolism Clinical and Experimental. 60 (1): 1244-1252.
* 1 2 3 4 5 6 7 8 Sigal, R., Kenny, G., Wasserman, D., & Castaneda-Sceppa, C. (2004). Physical Activity/Exercise and Type 2 Diabetes. Diabetes Care. 27(10): 2518-2539.
* 1 2 3 4 5 6 Durstine, J., Moore, G., Painter, P. & Roberts, S. (Eds.). (2009). ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, 3rd Edition. United States of America: Human Kinetics.
* 1 2 3 4 5 National Rural Health Alliance Inc. (2011). Physical Activity in Rural Australia. Fact Sheet 26. Accessed from www.ruralhealth.org.u
* 1 2 3 Department of Sport and Recreation. (2014). Indigenous Participation. Government of Western Australia. Accessed from www.vicsport.asn.au