Diabetes Integrated Wellness Society

Cardio Diabetic Workout

Aerobics is a form of physical exercise that combines rhythmic aerobic exercise with stretching and strength training routines with the goal of improving all elements of fitness (flexibility, muscular strength, and cardio-vascular fitness). It is usually performed to music and may be practiced in a group setting led by an instructor (fitness professional), although it can be done solo and without musical accompaniment. With the goal of preventing illness and promoting physical fitness, practitioners perform various routines comprising a number of different dance-like exercises.


Benefits of cardio are listed below:
  1. Weight loss
  2. Stronger heart and lungs
  3. Increased bone density
  4. Reduced stress
  5. Reduced risk of heart disease
  6. Temporary relief from depression and anxiety
  7. Increased Metabolism
  8. Better sleep
Stretching is a form of physical exercise in which a specific muscle or tendon (or muscle group) is deliberately flexed or stretched in order to improve the muscle’s felt elasticity and achieve comfortable muscle tone. The result is a feeling of increased muscle control, flexibility, and range of motion. Stretching is also used therapeutically to alleviate cramps. Increasing flexibility through stretching is one of the basic tenets of physical fitness. It is common for athletes to stretch before and after exercise in an attempt to reduce risk of injury and increase performance, though these practices are not always based on scientific evidence of effectiveness.


Benefits of stretching are listed below:
  1. Regular stretching can relieve stiff muscles and creaky joints.
  2. Stretching always keep you bright eyed
  3. regular stretching can help you achieve better form in just about any workout
  4. Incorporating stretching into your warm-up helps your body get ready for exercise as well as switch your brain into “workout mode”.
  5. Stretching lower your blood sugar
  6. Stretching can help tame tension both physically and mentally, as it relieves tight muscles while tricking you into feeling more relaxed.

Dance is a great form of exercise because it provides you with both aerobic and anaerobic movements. Our bodies need a combination of both types of exercise in order to be at their healthiest. In dance, aerobic exercise can be achieved by jumping, swaying, twirling, etc. Anaerobic exercises include holding squat positions, lifting someone else or your own body, and balancing. There are endless possibilities when it comes to getting a complete workout through dance. It helps us burn those calories away, while improving our stamina.


Benefits of dance are listed below:

  1. Improve flexibility
  2. Music inspires
  3. improved condition of your heart and lungs
  4. increased muscular strength
  5. endurance and motor fitness
  6. weight management

Regular physical activity can help protect you from serious diseases such as obesity, heart disease, cancer, mental illness, diabetes and arthritis. Riding your bicycle regularly is one of the best ways to reduce your risk of health problems associated with a sedentary lifestyle. Cycling is a healthy, low-impact exercise that can be enjoyed by people of all ages, from young children to older adults. It is also fun, cheap and good for the environment. Riding to work or the shops is one of the most time-efficient ways to combine regular exercise with your everyday routine. An estimated one billion people ride bicycles every day – for transport, recreation and sport.


Benefits of cycling are listed below:
  1. Low impact – it causes less strain and injuries than most other forms of exercise.
  2. A good muscle workout – cycling uses all of the major muscle groups as you pedal.
  3. Easy – unlike some other sports, cycling does not require high levels of physical skill. Most people know how to ride a bike and, once you learn, you don’t forget.
  4. Good for strength and stamina.
  5. As intense as you want – cycling can be done at very low intensity to begin with, if recovering from injury or illness, but can be built up to a demanding physical workout.
  6. A fun way to get fit – the adventure and buzz you get from coasting down hills and being outdoors means you are more likely to continue to cycle regularly, compared to other physical activities that keep you indoors or require special times or places.
  7. Time-efficient – as a mode of transport, cycling replaces sedentary (sitting) time spent driving motor vehicles or using trams, trains or buses with healthy exercise.
Any exercise is good exercise, but when it comes to losing weight, it’s hard to beat running. After all, running is one of the most efficient ways to burn calorie. Your glutes play a significant role in your running stride. They power your body forward, help you maintain proper torso alignment, and bear running loads. Glutes become weak or inhibited for a variety of reasons, including sitting all day. When your glute muscles (maximus, medius, minimus) are weak or inhibited, other muscles (quads, calves, hamstrings, etc.) are forced to carry loads they are not meant to carry, reducing running efficiency and increasing injury susceptibility.


Benefits of running are listed below:
  1. Running burns crazy calories
  2. Running doesn’t require a ton of equipment
  3. You can run anywhere / anytime
  4. Running strengthens your bones
  5. Running boosts your mood
  6. Running can make over your heart
  7. Running keeps your eyes healthy
  1. The first safety precaution is that you should stretch before and after doing such exercises. 
  2. Avoid training in the hottest part of the day, usually between 10 a.m. and 4 p.m., during the summer
  3. Keep yourself hydrated all
  4.  Start slowly and boost your activity level gradually.
  5. Listen to your body. Hold off on exercise when you’re sick or feeling very fatigued

Management and Diabetes

1) Controlling PPG & FPG together: the best approach for Indians- Dr. Vimal Upreti


Glucose control – The role of post-prandial hyperglycaemia

Rise PPG- better index of glycemic control

Rise in Ppg an early defect in t2dm


2) Premixes as a choice of insulin during the month of Ramadan - Dr. Anurag Rohatgi



3) Optimizing Insulin Intensification with Lispro Mix 50- Dr. MPS Chawla



4) GLP-1RA as first Injectable in Type 2 DM Management- Dr. CM Batra



Controlling PPG & FPG Together : The Best Approach For Indians

Vimal Upreti, KVS Hari Kumar, K S Brar


Type 2 diabetes mellitus is characterised by progressive and inexorable decline in beta cell function so much so that at onset almost 50 to 60% of beta cell function is lost, whereas, insulin resistance the other cardinal defect, gats stabilized after initial rise and remains fairly constant in the lifetime of an individual. This rapid decline in insulin secretion is unfortunately unavoidable and leads to progressive post-prandial hyperglycaemia. Targeting fasting plasma glucose is often insufficient to produce optimal HbA1c control though it is an integral part of glycemic control.
Glycemic control of an individual is best assessed by what is known as the “glucose triad” comprising of fasting plasma glucose (FPG), post prandial plasma glucose (PPPG) and glycosylated hemoglobin (HbA1c) and all three parameters of this triad need to be targeted. Traditional approach of targeting FPG (“Fix Fasting First”) is often an suboptimal strategy to achieve optimal glycemic control. Today, there is a growing understanding of the relevance of targeting post-prandial/ random plasma glucose in optimising HbA1c that is vital for prevention of both micro- and macrovasular complications of diabetes as a person spends more time in post prandial and postabsorptive than in a fasting state on any given day.

Post prandial hyperglycemia

Post- prandial hyperglycemia (PPHG) is defined as net rise of glucose from premeal lowest to post meal highest point. Various bodies categorize it at different values: ADA (180 mg/dl), AACE (140 mg/dl), IDF (145 mg/dl), however, most widely accepted value is any post- prandial value more than or equal to 140 mg/dl. It can be assessed by various parameters including self-monitoring of blood glucose (SMBG), continuous glucose monitoring (CGM), HbA1c that assesses control of previous 3 months and 1,5 – anhydro-glucitol that assesses control of preceding 2 weeks. Of these, HbA1c is most widely used strategy to find out status of glycemic control. It is well known that FPG is main determinant of HbA1c at higher and PPPG at lower values, so much so that, at a value > 10.2% FPG is contributes to 70% HbA1c while at a value <7.3% main determinant of HbA1c with PPPG accounting for 70% of it. These figures are derived from Western studies. In Indians and Asians, while PPPG forms higher component of HbA1C, it still remains bigger contributor to HbA1c at its higher values (about 50% at HbA1c>10.2%). It is a common experience that it is more difficult to control HbA1c when it is closer to 7% than when it is at a higher level. In these cases, it is therefore imperative to target PPG for better control.
Fasting plasma glucose on the other hand depends on a variety of factors including:

Elevation in postmeal plasma glucose occurs even prior to clinical diabetes. It depends on a variety of factors including:

Hence, in order to achieve HbA1c target an action is required both on FPG and PPG.
Factors responsible for PPHG are:
Hyperglycemia activates multiple mechanisms that mediate vascular damage. These include increased oxidative stress, overproduction of advanced glycosylation end products, increased activation of polyol pathway that lead to various micro- and macrovascular complications associated with PPHG.
Post prandial hyperglycemia is associated with multiple harmful effects that can be characterized on short term and long term basis:

a. Short Term ill effects of PPHG:

b. Long term ill effects of PPHG:

A meta-analysis of 38 prospective studies that included 194,658 patients over a mean follow-up period of 12.0 years showed that while postmeal hyperglycaemia is linearly related to CV risk across a wide range of postmeal glucose values, the trends observed for FPG are vastly different. The study by Levitan and colleagues analysed data from a subset of the original 38 studies (12 studies that reported FPG levels and 6 studies that reported postchallenge glucose) to allow for dose-response curve estimates. Risk of CV events increased in a linear fashion without a threshold for 2-hour PPG, whereas FPG showed a possible threshold effect at 5.6 mmol/L (100 mg/dL) with a steep rise in CV disease risk above this threshold value. That mealtime glucose spikes are associated with increased risk of cardiovascular disease and mortality is well established by many landmark trials including DECODE, Pacific and Indian Ocean study, Funagata Diabetes Study and The Rancho – Bernardo Study among others.

The India story

The prevalence of T2DM is increasing exponentially throughout the country though more in urban as compared to rural areas. Prevalence of T2 DM has increased from 8% (1980) to 16% (2006) in urban India in a very short span of time, specifically in Chennai.
Changes in our lifestyle namely poor dietary habits and sedentary lifestyle is largely to blame. Cereals are staple diet in India. Carbohydrates form bulk of the total calorie intake. Since 1980, the percentage of carbohydrate intake in Indian diets has remained relatively constant and is much higher than 55-65% of total calories as recommended by WHO. Excessive intake of white rice is frequently touted to be an important factor in causation of T2DM in Indians, specially in the southern part. Dietary rice is a major contributor to glycemic load. White rice loses its protective factors during polishing that include dietary fibres, magnesium, vitamins, lignans and phytoestrogens. But, is dietary white rice the real culprit? Arguments opposing this hypothesis include
Dietary advice to prevent PPHG

Management of PPHG and FPG: The Best Approach For Indians

Ensuing from above discussion it is clear that whereas controlling FPG has remained the bottom line of treatment in the management of T2DM, PPHG also assumes equal importance so far as to effective control of HbA1c in Indians.
Agents predominantly effective in controlling FPG:



Basal insulins

Agents predominantly effective in controlling PPHG:

α-glucosidase inhibitor

DPP-4 inhibitors


Amylin analogues

GLP-1 agonist

Bolus insulins

Agents effective in controlling both FPG and PPHG:


SGLT2 inhibitors

Insulins – premix, basal bolus regimen

Among the insulins intermediate/ long acting basal insulins including analogues target the FPG while short/ rapid acting insulins target the PPHG. Premix insulins are a mixture of both short and long acting insulins and can potentially target both FPG and PPG. Indeed, various short term studies have confirmed this and various professional bodies such ADA, EASD, IDF and NICE support the use of premix insulins. In India, Indian Premix Guidelines also advocate the use of premix insulins as they are simple to start, convenient, no mixing required (less dosing error) and is easy to intensify using the same insulin. High ratio premix insulins can be given in cases of failure of low ratio premixes in order to intensify as it has been found to be as effective as basal bolus therapy in small studies.


Suggested reading