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ACSM’s Certified News JULY-SEPTEMBER 2007 VOLUME 17, ISSUE 3 News You Need Diabetes Mellitus: An Overview Certification Updates Summer 2007 by: Mike Niederpruem, National Director of Certification and Registry Programs ACSM’s Committee on Certification and Registry Boards, 2006-07 Milestones Each year, the ACSM Committee on Certification and Registry Boards (CCRB) provides an annual update on CCRB activity at a public colloquium that takes place during the ACSM Annual Meeting. There is always great news to share, and this year in New Orleans was no exception. As a result of all the hard work of our CCRB volunteers over the last year, here are a few of our accomplishments: • Achieved Successful Accreditation from the National Commission for Certifying Agencies (NCCA) ACSM Certified Personal Trainer SM ACSM Health/Fitness Instructor ® ACSM Exercise Specialist ® ACSM Registered Clinical Exercise Physiologist ® • Released the Following New Publications ACSM’s Resources for the Personal Trainer, Second Edition ACSM’s Health/Fitness Facility Standards and Guidelines, Third Edition ACSM’s Health-Related Physical Fitness Assessment Manual, Second Edition ACSM’s Metabolic Calculations Hand- book, First Edition • Established Partnership with National Intramural-Recreational Sports Association (NIRSA) • Launched the ACSM Club Connection Program • Developed a Free Interactive Exam Tutorial • Completed Successful Job Task Analyses for All Certification Programs • Launched a New CEC course: Behavior Change Strategies for Optimal Client Outcomes IN THIS ISSUE News You Need 1 Diabetes Mellitus: An Overview 1 Overview of Type 2 Diabetes 3 Type 1 Diabetes and Exercise 5 Coaching News 7 Avoiding Possible Interactions Between 8 Exercise and Diabetic Medications Self-Tests 11 Larry S. Verity, Ph.D., FACSM, Professor of Exercise Physiology, School of Exercise & Nutritional Sciences, San Diego State University News You Need... Continued on Page 12 In this themed issue of ACSM’s Certified News, experts provide an overview and rec- ommendations for fitness practitioners to improve awareness and development of exer- cise programs for those with Type 1 and Type 2 Diabetes. Marialice Kern, Ph.D., addresses exercise recommendations for Type 1 Diabetes Mellitus (T1DM), while Larry S. Verity, Ph.D., reviews exercise recommenda- tions for Type 2 Diabetes Mellitus (T2DM). Lastly, Sheri Colberg-Ochs, Ph.D., highlights the interaction of exercise with common dia- betes medications. Each of these three authors are professionals in the field of diabetes and have lived with T1DM for 25 years or more. As an overview, diabetes mellitus is a group of diseases marked by elevated blood glucose levels resulting from defects in insulin production, insulin action, or both. Overall, diabetes can lead to serious complications and premature death, yet those with Diabetes can take action to control their disease and lower their risk of complica- tions. In the United States, the prevalence of diabetes is about 20.8 million people 1,2 . The significance and burden of diabetes towards the heath care system is reflected in the following 1,2 : • Diabetes is one of the most common chronic diseases affecting people in the United States. More than 1.5 million new cases are diagnosed annually. • Diabetes has a major impact on the health of the U.S. population. It is the leading cause of new blindness, end- stage renal disease, and nontraumatic amputations in adults. • Direct medical costs and indirect costs of diabetes total $132 billion annually (based on 2002 estimates). • Sixth leading cause of death in U.S. (fifth leading cause of death for women) • Overall, the risk of death among people with diabetes is about twice that of people without diabetes of similar age. • Cardiovascular disease 2 to 4-fold in cardiovascular disease About 73 percent of adults with dia- betes have a blood pressure greater than or equal to 130/80 mm Hg Diabetes Mellitus... Continued on Page 2

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Page 1: ACSM Diabetes

ACSM’s

CertifiedNewsJULY-SEPTEMBER 2007 VOLUME 17, ISSUE 3

News You Need Diabetes Mellitus: An OverviewCertificationUpdates

Summer 2007by: Mike Niederpruem, National

Director of Certification andRegistry Programs

ACSM’s Committee onCertification and Registry Boards,2006-07 Milestones

Each year, the ACSM Committee onCertification and Registry Boards (CCRB)provides an annual update on CCRB activityat a public colloquium that takes place duringthe ACSM Annual Meeting. There is alwaysgreat news to share, and this year in NewOrleans was no exception. As a result of allthe hard work of our CCRB volunteers over the last year, here are a few of ouraccomplishments: • Achieved Successful Accreditation from the

National Commission for CertifyingAgencies (NCCA)

ACSM Certified Personal TrainerSM

ACSM Health/Fitness Instructor®

ACSM Exercise Specialist®

ACSM Registered Clinical ExercisePhysiologist®

• Released the Following New PublicationsACSM’s Resources for the PersonalTrainer, Second EditionACSM’s Health/Fitness Facility Standardsand Guidelines, Third EditionACSM’s Health-Related Physical FitnessAssessment Manual, Second EditionACSM’s Metabolic Calculations Hand-book, First Edition

• Established Partnership with NationalIntramural-Recreational Sports Association(NIRSA)

• Launched the ACSM Club ConnectionProgram

• Developed a Free Interactive Exam Tutorial• Completed Successful Job Task Analyses for

All Certification Programs• Launched a New CEC course: Behavior

Change Strategies for Optimal ClientOutcomes

IN THIS ISSUENews You Need 1Diabetes Mellitus: An Overview 1Overview of Type 2 Diabetes 3Type 1 Diabetes and Exercise 5Coaching News 7Avoiding Possible Interactions Between 8

Exercise and Diabetic MedicationsSelf-Tests 11

Larry S. Verity, Ph.D., FACSM, Professor of Exercise Physiology, School of Exercise &Nutritional Sciences, San Diego State University

News You Need... Continued on Page 12

In this themed issue of ACSM’s CertifiedNews, experts provide an overview and rec-ommendations for fitness practitioners toimprove awareness and development of exer-cise programs for those with Type 1 and Type2 Diabetes. Marialice Kern, Ph.D., addressesexercise recommendations for Type 1Diabetes Mellitus (T1DM), while Larry S.Verity, Ph.D., reviews exercise recommenda-tions for Type 2 Diabetes Mellitus (T2DM).Lastly, Sheri Colberg-Ochs, Ph.D., highlightsthe interaction of exercise with common dia-betes medications. Each of these three authorsare professionals in the field of diabetes andhave lived with T1DM for 25 years or more.

As an overview, diabetesmellitus is a group of diseasesmarked by elevated bloodglucose levels resulting fromdefects in insulin production,insulin action, or both.Overall, diabetes can lead toserious complications andpremature death, yet thosewith Diabetes can take actionto control their disease andlower their risk of complica-tions. In the United States, theprevalence of diabetes isabout 20.8 million people1,2.The significance and burdenof diabetes towards the heathcare system is reflected in thefollowing1,2:• Diabetes is one of the most

common chronic diseasesaffecting people in theUnited States. More than1.5 million new cases arediagnosed annually.

• Diabetes has a major impacton the health of the U.S.population. It is the leadingcause of new blindness, end-stage renal disease, andnontraumatic amputationsin adults.

• Direct medical costs andindirect costs of diabetestotal $132 billion annually(based on 2002 estimates).

• Sixth leading cause of death in U.S. (fifthleading cause of death for women)

• Overall, the risk of death among peoplewith diabetes is about twice that of peoplewithout diabetes of similar age.

• Cardiovascular disease2 to 4-fold in cardiovascular diseaseAbout 73 percent of adults with dia-betes have a blood pressure greater thanor equal to 130/80 mm Hg

Diabetes Mellitus... Continued on Page 2

Page 2: ACSM Diabetes

ACSM’S CERTIFIED NEWSEDITORS

Paul Sorace, M.S.Larry S. Verity, Ph.D., FACSM

COMMITTEE CHAIRDino Costanzo, M.A., FACSM

CCRB PUBLICATIONS SUBCOMMITTEE CHAIRJonathan N. Myers, Ph.D., FACSM

ADMINISTRATIONPRESIDENT

Robert E. Sallis, M.D., FACSMPUBLICATIONS COMMITTEE CHAIR

Jeffrey L. Roitman, Ed.D., FACSMEXECUTIVE VICE PRESIDENT

James R. WhiteheadNATIONAL CENTER NEWSLETTER STAFFNATIONAL DIRECTOR OF CERTIFICATION

AND REGISTRY PROGRAMSMike Niederpruem

ASSISTANT DIRECTOR OF CERTIFICATIONHope Wood

MANAGER, CERTIFICATION PROGRAMSTraci Rush

CERTIFICATION PROGRAM COORDINATORBeth Muhlenkamp

PROFESSIONAL EDUCATION COORDINATORGretchen Dovenmuehle

DIRECTOR OF PROFESSIONAL EDUCATIONAND DISTANCE LEARNING

Karen J. PierceASSISTANT EXECUTIVE VICE PRESIDENT, GROUP PUBLISHER

D. Mark RobertsonSENIOR DIRECTOR OF PUBLICATIONS AND MARKETING

Jeff RichardsonPUBLICATIONS MANAGER

David BrewerFOR MORE CERTIFICATION RESOURCES CONTACT

THE ACSM CERTIFICATION RESOURCE CENTER:1-800-486-5643

INFORMATION FOR SUBSCRIBERSCORRESPONDENCE REGARDING EDITORIAL CONTENT

SHOULD BE ADDRESSED TO:Certification & Registry Department

E-mail: [email protected].: (317) 637-9200, ext. 121

CHANGE OF ADDRESSOR MEMBERSHIP INQUIRIES

MEMBERSHIP AND CHAPTER SERVICESTEL.: (317) 637-9200, EXT. 139 OR EXT. 136.

ACSM’s Certified News (ISSN# 1056-9677) is publishedquarterly by the American College of Sports MedicineCommittee on Certification and Registry Boards (CCRB). Allissues are published electronically and in print.The articles published in ACSM’s Certified News have beencarefully reviewed, but have not been submitted forconsideration as, and therefore are not, officialpronouncements, policies, statements, or opinions of ACSM.Information published in ACSM’s Certified News is notnecessarily the position of the American College of SportsMedicine or the Committee on Certification and RegistryBoards. The purpose of this newsletter is to inform certifiedindividuals about activities of ACSM and their profession andabout new information relative to exercise and health.Information presented here is not intended to be informationsupplemental to the ACSM’s Guidelines for Exercise Testingand Prescription or the established positions of ACSM.ACSM’s Certified News is copyrighted by the American Collegeof Sports Medicine. No portion(s) of the work(s) may bereproduced without written consent from the Publisher.Permission to reproduce copies of articles for noncommercialuse may be obtained from the Rights and Permissions editor.

ACSM NATIONAL CENTER

401 WEST MICHIGAN ST.INDIANAPOLIS, IN 46202-3233.

TEL.: (317) 637-9200 • FAX: (317) 634-7817

© 2007 American College of Sports Medicine.ISSN # 1056-9677

2ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

• Leading cause of:Non-traumatic amputations (82,000/year or 224/day) — More than 60 per-cent of nontraumatic lower-limb ampu-tations occur in people with diabetes.Blindness (~20,000/year or 60/day)End stage renal disease (38,000/year or104/day)Neural Defects: About 60-70 percent ofpeople with diabetes have mild to severeforms of nervous system damage.Almost 30 percent of people with dia-betes aged 40 years or older haveimpaired sensation in the feet (i.e., atleast one area that lacks feeling).

Based on these disease-related conse-quences of diabetes, it is imperative for healthfitness practitioners to understand exerciserisks, benefits, and precautions for those withdiabetes. Although there are three main typesof Diabetes Mellitus1, we focus only onT1DM and T2DM in this issue. GestationalDiabetes Mellitus (GDM) is not addressed;however, many GDM strategies align closelywith those for T2DM.

Briefly, T1DM develops when the body’simmune system destroys insulin-producingcells that regulate blood glucose. To survive,people with T1DM must have insulin deliv-ered by injection or a pump, while some douse inhaled insulin. This form of diabetes usu-ally strikes children and young adults,although disease onset can occur at any age.T1DM accounts for 5-10 percent of all diag-nosed cases of diabetes1. Risk factors forT1DM may be autoimmune, genetic, or envi-ronmental. Presently, there is no known wayto prevent T1DM, even though there areknown biologic markers increasing risk forT1DM.

T2DM is the most common form of dia-betes and accounts for about 90-95 percent ofall diagnosed cases1. It usually begins asinsulin resistance, a disorder in which insulinreceptor sites on the target cell are impaired.

As the need for insulin rises, the pancreasgradually loses its ability to produce it. T2DMis associated with older age, obesity, familyhistory of diabetes, history of GDM, impairedglucose metabolism, physical inactivity, andrace/ethnicity. Moreover, T2DM in childrenand adolescents is more commonly diagnosed,particularly in American Indians, AfricanAmericans, and Hispanic/Latino Americans.

Treating diabetes requires timely medica-tion(s) use, proper nutrition, and regular phys-ical activity/exercise to aid in regulating bloodglucose. Diabetes self-management education(DMSE) is an integral component of medicalcare, especially routine glucose monitoring,which aids in glucose control and benefits bothT1DM and T2DM. To avoid acute risks ofexercise (e.g., high or low blood glucose), it isstrongly recommended that blood glucosemonitoring be performed before/after eachexercise/physical activity session.

Health fitness practitioners need to knowthe role of exercise in diabetes — risks, bene-fits, and precautions. Overall, if a client withdiabetes does not have disease-related compli-cations (e.g., heart and vessel, eye, kidney, ornerve), then the recommendations put forth inthis themed issue are prudent for the healthfitness practitioner. If there are known com-plications, physician-directed exercise and/orphysical activity planning and development iswarranted.

References1. American Diabetes Association: Standards of Medical Care in

Diabetes: Position Statement. Diabetes Care, 30 (suppl1):S4–S41, 2007.

2. U.S. Centers for Disease Control and Prevention. National dia-betes fact sheet: general information and national estimates ondiabetes in the United States, 2005. Atlanta, GA: U.S.Department of Health and Human Services, Centers for DiseaseControl and Prevention, 2005.

Diabetes Mellitus... Continued from Page 1

SELF-TEST ANSWER KEY FOR PAGE 11————— QUESTION ——————1 2 3 4 5

TEST #1: C B B A CTEST #2: B D D A ETEST #3: A A E B D

Page 3: ACSM Diabetes

Type 2 Diabetes Mellitus (T2DM) is a sig-nificant health burden in the United States dueto increased morbidity and mortality associat-ed with macrovascular and microvascular dia-betes complications9. The rate of growth inT2DM both nationally9 and globally10 is pro-jected to double by 2050 and 2025, respec-tively. One in three people born in the UnitedStates in 2000 are projected to develop dia-betes in their lifetime13. While the prevalenceof T2DM is common among all elderly andobese, selected minority and ethnic groups aredisproportionately affected6,8,9. Moreover, per-sons with diabetes suffer disproportionatelyfrom physical and cognitive disability9.

Usually, T2DM afflicts adults over 30 yearsand is directly related to co-existing condi-tions, such as obesity, hypertension, dyslipi-demia, and insulin resistance6,7. Alarmingly,the incidence of T2DM in children and ado-lescents has significantly increased over thepast 20 years, presumably related to increasedlevels of obesity secondary to excess caloricintake and too little caloric expenditure6.About 85 percent of children diagnosed withT2DM are overweight or obese at diagnosis5.The inextricable relationship between T2DMand obesity in adults and youth has promptedthe development of the term Diabesity® whichis trademarked by Shape Up America.Diabesity refers to the link between obesityand T2DM — the most prevalent form of dia-betes in America14.

Although T2DM displays varying degreesof insulin production (e.g., normal or elevat-ed), the disease is characterized by insulinresistance. Insulin resistance is considered a“peripheral defect” because of a decrease ininsulin-mediated uptake and storage of glu-

cose in the liver and skeletal muscle12,16.Reduced insulin receptor binding at target tis-sues and impaired post-binding activitiesrelated to intracellular insulin action result ininsulin resistance. Interestingly, these abnor-malities are reversible with weight loss, diet,and physical activity12. Elevated blood glu-cose, or hyperglycemia in T2DM suggests thatinsulin release is inadequate to compensate forthe insulin resistance. At diagnosis, T2DMhave significantly elevated levels of insulin,which contributes to insulin resistance. Overtime, the pancreas loses its ability to produceinsulin, and the need for exogenous insulin tocontrol blood glucose increases. Thus, T2DMis a progressive disease occurring in a gradualsuccession of stages of increasing glucoseintolerance and insulin resistance6.

Onset of T2DM is associated with genetic,environmental, and cultural factors5. The riskof disease rises with family history, age, obesi-ty, and inactivity7,9. About 80 percent ofadults with T2DM are obese and physicallyinactive, both of which are related toincreased insulin resistance6. Lifestyle inter-ventions focusing on weight loss and physicalactivity are essential strategies to not onlymanage glucose levels and lessen the onset ofdisease-related complications, but also to pre-vent the onset of T2DM1,11,12. Moreover,aggressive lifestyle intervention can actuallyreduce the amount of medication (e.g., oraldrugs and exogenous insulin) required tomanage T2DM.

Blood glucose control for T2DM is crucialin managing the disease and lessening theonset of cardiovascular disease and diabetes-related complications (DRCs)4. Because dia-betics are two to four times more likely thannondiabetics to suffer a fatal heart attack orstroke6,7, the health fitness practitioner shouldensure that their client with T2DM monitorshis/her blood glucose and manages CVD riskfactors. Overall glycemic control is routinelyassessed using glycosylated hemoglobin (A1c).A1c gives a measure of average glucose overthe preceding two to three months and thegoal for diabetes from the American DiabetesAssociation (ADA) is to have an A1c value <7.0 percent6; however, the AmericanAssociation of Clinical Endocrinologist(AACE) has recommended an A1c value <6.5percent .

In addition to elevated blood glucose, mul-tiple co-existing risk factors for heart diseaseare typically present in T2DM including obe-sity, hypertension, dyslipidemia, and physicalinactivity6,8. Obesity predominates in T2DMwith body mass index (BMI) often exceeding30 kg•m2 and abdominal girth being quitelarge. This type of morphology places manywith T2DM at high risk for heart disease andcancer5,8. Therefore, weight loss is a primarytreatment goal to improve insulin action inpersons with T2DM6,7,8.

The primary goal of therapy for all diabet-ics focuses on Diabetes Self MonitoringEducation (DSME) and Self Blood GlucoseMonitoring (SBGM) to achieve acceptableblood glucose control (HbA1c < 7.0 percent)based upon ADA guidelines, thereby limitingthe development and progression of diabetes-related complications6. Persons with T2DMshow reduced risk for retinopathy, nephropa-thy, and neuropathy with intensive therapyand the potential for a reduction of cardiovas-cular disease with improved glycemic con-trol4. Glycemic control is best achievedthrough DSME and SBGM combined withnutrition, adjustment of diabetes medications,and regular physical activity6,15.

Cardiovascular risk factors, along withsymptomatic and asymptomatic coronaryheart disease, are far too common inT2DM6,7,8. Recently, a call to action was putforth by the ADA and AHA to prevent cardio-vascular disease and diabetes8. Diagnosis ofmacrovascular disease and co-morbid condi-tions of diabetes coupled with aggressiveintervention is crucial in minimizing progres-sion of this disease8.

Pre-Activity ScreeningA thorough pre-activity screening of the

patient’s clinical status is recommended toensure safe and effective participation1,2,11,15.Before commencing exercise, prudent screen-ing for vascular and neurological complica-tions, including silent ischemia, are warranted,along with identification of the presence ofcardiovascular disease risk factors15.Coexisting morbidities in the diabetes healthprofile are important for the health fitness

3JULY/AUGUST/SEPTEMBER 2007 | VOLUME 17; ISSUE 3 ACSM’s Certified News

Table 1: Indications For StressTesting with Diabetes6,15

• Known or suspected cardiovascular disease(e.g., CAD, PAD)

• Age > 35 years• Age > 25 years if duration of diabetes > 10 years for

type 2 or > 15 years for type 1• Presence of any additional risk factors for

cardiovascular disease• Microvascular disease• Proliferative retinopathy• Nephropathy, including microalbuminuria• Peripheral Vascular Disease• Autonomic neuropathy

CAD = coronary artery disease; PAD = peripheral arterial disease

Type 2 Diabetes... Continued on Page 4

Larry S. Verity, Ph.D., FACSMProfessor of Exercise PhysiologySchool of Exercise & Nutritional SciencesSan Diego State University

Overview of Type 2 Diabetes

Page 4: ACSM Diabetes

4ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

practitioner to determine whether the clientstatus is acceptable for safely engaging in exer-cise and to determine the need for monitoringof each session. Use of the PAR-Q and PAR-MedX questionnaires are helpful screeningtools for the health fitness practitioner toensure medical oversight in evaluating theclient’s health profile. Persons with diabetesare stratified in the high-risk category, accord-ing to recommended guidelines3, and a stresstest is strongly advised before initiating moder-ate to vigorous exercise irrespective of thepatient’s cardiac risk profile3,6,15. Specific indi-cations for a stress test to be administeredinclude the presence of one or more of the cri-teria shown in Table 1.6,15

Exercise: Benefits for Type 2 Diabetes

The benefits of regular exercise for T2DMare significant and over the past 20 years thepowerful role of exercise and physical activityhas become more fully appreciated in treatingand preventing T2DM1,2,12,15,16. The molecularunderstanding of exercise in relation to T2DMis evolving, as is knowledge regarding the opti-mal mode, frequency, and duration of exerciseto treat and prevent this disorder1,2,6,1115. Inaddition, there is a growing appreciation forthe role of aerobic exercise, as well as resist-ance training, in T2DM1,6,15. Although DRCshave been the premise to discourage exerciseparticipation, there are a variety of activitiesthat allow for safe exercise in a supervised set-ting to oversee diabetes and DRCs. Individ-ualized exercise training needs to be an integralpart of the treatment plan for the managementof T2DM. It is important for the health fitnesspractitioner to ensure the development of asafe and effective program for the client withT2DM through physician interaction.

Exercise Program for Type 2 Diabetes:

Current exercise recommendations forT2DM attempt to enhance the volume ofweekly aerobic physical activity, along withincreasing the quantity and quality of resist-ance training sessions6,15. These recommenda-tions address important outcomes aimed atimproved glucose management, reduced heartdisease risk, and favorable psychoemotionalchanges that lessen/delay progression of thedisease. Proper precaution of exercise partici-pation is prudent with T2DM clientele, espe-cially, monitoring blood glucose before/afterexercise. Finally, the recommendations putforth in this article are limited to persons withT2DM who do not have DRCs. If DRCs arepart of a client’s health profile, it is importantfor the health fitness practitioner to have med-ical oversight in developing a safe and effec-tive exercise program for those with T2DM,and maybe recommend clinical supervisionfor safe participation.

The aerobic exercise recommendations pre-sented in ACSM’s Guidelines for ExerciseTesting and Prescription, Seventh Edition.(GETP7) for “all diabetes” needs to be modi-fied to meet specific needs of the client withT2DM3. As presented in Table 2, the FITTrecommendations in GETP7 are comparedwith current recommendations for T2DM3,15.The more current aerobic activity is recom-mended not only to improve glucose metabo-lism and glucose control, but also to aid inweight management and cardiovascular riskprevention6,15. Coupled with obesity, healthfitness professionals should strive to havetheir client with T2DM achieve at least 150minutes of moderate intensity physical activi-ty each week, and may need to increase theamount of time in physical activity/resistancetraining to aid in weight management15.

In addition to aerobic exercise, resistancetraining is strongly recommended for T2DM.In recent years, many studies have examinedthe benefits, effectiveness, and safety of resist-ance training in T2DM. The current guide-lines (see Table 2) recommend that resistancetraining be performed up to three times perweek for clients with T2DM6,15. Moreover,eight or more exercises should be included inthis training with eight to ten repetitions (e.g.,8-10 RM) of each exercise performed per set,while the number of sets should progress fromone to three. Most importantly, health fitnesspractitioners must supervise and assess theirclients with T2DM to ensure the proper safe-ty, progression, and effectiveness of the train-ing program. Irrespective of aerobic orresistance training, the health fitness practi-tioner should design an exercise program toaccommodate the clinical status of thepatient\client and specify the type and intensi-ty of activity as well as duration and frequency.

In summary, the health fitness practitionercan safely and effectively accomplish exerciseprogram development for T2DM. It is impor-tant to consider current health and DRC sta-tus before physical activity participation.Participation in physical activity affords criti-cal benefits for those with T2DM, whilehealth fitness practitioners need to keep close

scrutiny over the intensity of the exercise pro-gram to yield both safe and effective outcomesfor this clientele.

References1. Albright, A., M. Franz, G. Hornsby, A. Kriska, D. Marrero, I.

Ulrich, and L.S. Verity. American College of Sports Medicine.Exercise and Type 2 Diabetes. Position Stand. Medicine &Science in Sports & Exercise, 32:1345–1360, 2000.

2. American College of Sports Medicine and American DiabetesAssociation. Diabetes Mellitus and Exercise: A joint positionstatement of the American College of Sports Medicine and TheAmerican Diabetes Association. Medicine & Science in Sports &Exercise, 29:i–vi, 1997.

3. American College of Sports Medicine. ACSM’s Guidelines forExercise Testing and Prescription, 7th ed.Philadelphia:Lippincott, Williams & Wilkins, 2006.

4. American Diabetes Association: Implications of the UnitedKingdom Prospective Diabetes Study: Position Statement.Diabetes Care, 26(suppl 1):S28–S32, 2003.

5. American Diabetes Association (2000). Type 2 diabetes in chil-dren and adolescents (Consensus Statement, 2000). DiabetesCare, 23(3): 381–389.

6. American Diabetes Association: Standards of Medical Care inDiabetes: Position Statement. Diabetes Care, 30 (suppl1):S4–S41, 2007.

7. Centers for Disease Control and Prevention. National diabetesfact sheet: general information and national estimates on diabetesin the United States, 2005. Atlanta, GA: U.S. Department ofHealth and Human Services, Centers for Disease Control andPrevention, 2005.

8. Eckel, R.H., R. Kahn, R.M. Robertson, and R.A. Rizza.Preventing Cardiovascular Disease and Diabetes: A Call toAction From the American Diabetes Association and theAmerican Heart Association. Circulation, 113:2943-2946, 2006.

9. Engelgau, M.M., L.S. Geiss, J.B. Saaddine, J. Boyle, S. Benjamin,E. Gregg, E.Tierney, N. Rios-Burrows, A.H. Mokdad, E.S. Ford,G. Imperatore, and K. Venkat Narayan. The Evolving DiabetesBurden in the United States. Annals of Internal Medicine,140(11):945-950, 2004.

10. Green, A., N.C. Hirsch, and S.K. Pramming. The ChangingWorld Demography of Type 2 Diabetes. Diabetes/MetabolismResearch and Reviews, 19:3-7, 2003.

11. Hornsby W.G. and A.L. Albright. Diabetes (pp. 133–41). In:ACSM’s Exercise Management for Persons with ChronicDisease and Disabilities, 2nd ed., Durstine L and G Moore(Editors), Champaign, IL: Human Kinetics; 2003.

12. Ivy, J.L., T.W. Zderc, and D.L. Fogt (1999). Prevention andTreatment of Non-Insulin Dependent Diabetes Mellitus. (pp. 1-35). In: Exercise and Sport Science Reviews, vol. 27, J.O.Holloszy (Editor). Lippincott Williams & Wilkins:Philadelphia, PA.

13. Narayan, K.M., J. Boyle, T. Thompson, S.W. Sorensen, and D.F. Williamson. Lifetime Risk for Diabetes Mellitus in theUnited States. Journal of the American Medical Association,290:1884-1890, 2003.

14. Shape Up America! Healthy Weight For Life [http://www.shape-up.org/prof/diabesity.php]

15. Sigal, R.J., G.P. Kenny, D.H. Wasserman, and C. Castaneda-Sceppa. Physical Activity/Exercise and Type 2 Diabetes:Technical Review. Diabetes Care, 27 (10): 2518-2539, 2004.

16. Riddell M.C., N. Ruderman, M. Berger, and M. Vranic:Exercise physiology and diabetes: From antiquity to the age ofthe exercise sciences (pp. 3–15). In: Handbook of Exercise inDiabetes, 2nd ed., Ruderman N, J Devlin, S Schneider, and AKriska,(Editors). Alexandria, VA: American DiabetesAssociation; 2002.

Table 2: Comparing Aerobic and Resistance Training Recommendationsfor Type 2 Diabetes

Aerobic Training Recommendations Resistance Training Recommendations

GETP7 - Diabetes Current Type 2 ACSM Current Type 2Diabetes Position Stand Diabetes

Recommendations (2000) Recommendations

Frequency 3-4 days/week 3-7 days/week > 2 days/week > 3 days/weekIntensity 50-80% HRR 40-60% HRR* 10-15 repetitions 8-10 repetitions

> 60% HRR**Time 20-60 minutes > 150 minutes/week* 8-10 exercises > 8 exercises

> 90 minutes/week** > 1 set per exercise up to 3 sets perexercise

Type or Mode aerobic aerobic

*Moderate intensity; ** Vigorous intensity

Page 5: ACSM Diabetes

5JULY/AUGUST/SEPTEMBER 2007 | VOLUME 17; ISSUE 3 ACSM’s Certified News

IntroductionBetween Type 1 Diabetes Mellitus (T1DM)

and Type 2 Diabetes Mellitus (T2DM),T1DM is significantly less prevalent8. T1DM,formerly known as juvenile onset or insulindependent, afflicts more than one million peo-ple in the United States. Though the clinicalsymptoms for both types are the same(polyuria (excessive urination), polydipsia(excessive drinking/thirst), polyphagia (exces-sive eating/hunger), blurred vision and/orweight loss), disease etiology for T1DM isbased on an autoimmune disorder whichresults in the destruction of the beta (β)-cellsof the pancreas8. These cells produce insulin,an anabolic hormone which is necessary forlife. Because T1DM lacks insulin production,this hormone must be taken via subcutaneousinjection using either a needle (usually severalshots/day) or an insulin-pump (continuousinsulin infusion, with bolus amounts givenwith meals). The quantity of insulin each per-son with T1DM must take per day is depend-ent on their sensitivity to insulin, and thissensitivity can change significantly dependingon an individual’s exercise habits. It is impor-tant that exercise professionals understand thepathology of diabetes and possible complica-tions, and benefits that are associated withexercise in T1DM if they are going to proper-ly prescribe an exercise program which willhelp the T1DM have a better quality of life.

Pathological Physiology ofDiabetes

The symptoms and complications associat-ed with T1DM can be attributed to a lack ofcirculating insulin: (a) decreased utilization ofglucose by the body cells, resulting in highblood glucose, (b) increased mobilization anduse of fats, resulting in ketoacidosis, and (c)depletion of amino acids. For T1DM, the pri-mary defect is inadequate insulin secretion sec-ondary to progressive destruction ofpancreatic β-cells via an autoimmune process.There is clinical evidence suggesting that indi-viduals who develop with T1DM are geneti-cally predisposed to this β-cell destruction5.This evidence is several fold. At the time ofdiagnosis, the presence of anti-insulin and anti-islet cell antibodies is seen in the blood, alongwith the presence of inflammatory cellsaround the islets. T-lymphocytes are also acti-vated. Genes located on chromosome 6, theHLA (Human Leukocyte Antigens) genes, helpthe immune system to distinguish betweenone’s own cells and foreign cells. There aremany different alleles (copies) of the HLAgenes. The genetic risk of inheriting T1DM isexplained in over 50 percent of the cases by thepresence of the genes HLA-DR, HLA-DQ, andHLA-DP10. Specifically, in the general popula-tion, only 50 percent of the population inher-its a copy of the DR genes DR3 and DR4, andless than three percent have two alleles. But, in

T1DM, at least one allele of DR3 or DR4 isfound in 95 percent of caucasians, with theprevalence of developing T1DM even higher ifthe individual has both DR3 and DR412.Persons with T1DM also have a higher inci-dence of other known autoimmune diseases(arthritis, Addison’s, Hashimoto thyroiditis,and multiple sclerosis)5.

Symptoms of T1DM will occur when 80 to90 percent of the β-cell mass is destroyed8.The lack of insulin results in several intracellu-lar abnormalities in both muscle and liver suchas excessive hepatic glucose production,decreased muscle glucose uptake, and glucoseintolerance11. When insulin is secreted fromthe pancreas, it is dumped into the venouseffluent, where it directly passes through theliver. Normally, 50 percent of the insulin isremoved from the circulation on this first pass.If there is no insulin being secreted, there is no“cap” on the insulin counter-regulatory hor-mones: glucagon, catecholamines, growth hor-mone, and glucocorticoids. This results in anincrease in hepatic glucose output and adecreased extraction of glucose from the bloodby the periphery. If the liver is dumping glu-cose, and the skeletal muscle is not able to takethat glucose inside the cell, high blood glucoselevels develop and continue to increase. Thisis uncontrolled diabetes, and, in its worseform, results in dehydration, loss of acid-basebalance, circulatory shock and death.

Without the help of insulin, glucose doesnot diffuse easily across cell membranes. Highconcentrations of glucose cause a fluid shift asthe body tries to equalize the osmotic pressurebetween the intracellular and extracellularfluid. Both intracellular and extracellular fluidsare lost in uncontrolled diabetes. Increasedosmotic pressure in the extracellular fluid(where there is a high concentration of glu-cose) results in a shift of water from the intra-cellular fluid to the extracellular fluid. Whenblood glucose levels are greater than ~ 180mg/dl, glucose spills into the urine7.Extracellular fluid is lost by water followingthe glucose in the urine (osmotic diuresis). Thisis due to the osmotic effect of glucose in therenal tubules which greatly decreases tubularreabsorption of water by the kidneys, causingcellular dehydration11.

At this point in time, the body is sensingstarvation, and shifts its fuel source from glu-cose to fat and protein. Increased fat metabo-lism results in increased keto acid levels(acetoacetic and β-hydroxybutyric) in theblood, creating diabetic ketoacidosis. Whenfats are supplying the primary fuel source, con-centrations of ketone bodies (ketoacidosis) inthe blood may increase tenfold or higher7. Tocompound the problem, ketone bodies have alow threshold for excretion by the kidneys,and because they are strong acids, they arepartially neutralized by sodium ions from the

Type 1 Diabetes and ExerciseMarialice Kern, Ph.D., FACSM, Professor of Exercise Physiology, San Francisco StateUniversity

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extracellular fluid. These sodium ions arereplaced with hydrogen ions, which make theblood even more acidic. If the mechanismsmentioned above continue for weeks tomonths, death can occur. First priority for theperson with T1DM when admitted to the hos-pital in diabetic ketoacidosis (diabetic coma),is to normalize his/her electrolytes and bicar-bonate stores which will restore the blood pH.This is more important than normalization ofthe blood glucose.

We can see how this explains the previouslymentioned symptoms!• Polyuria: blood glucose higher than kidney

“threshold” (usually ~180 mg/dl), glucosewill spill into the urine.

• Polydipsia: tissue dehydration triggers theexcessive thirst.

• Weight loss: body is wasting away (meltinginto the urine), increased fat metabolism andprotein breakdown to supply the necessaryintermediates to oxidize fat.

• Polyphagia: constant hunger, as the cellssense lack of fuel.

Exercise and Type 1 DiabetesGiven the scenario depicted above, what

are the benefits of maintaining a regular exer-cise program for persons with T1DM?Regular exercise allows the person with dia-betes the same advantages seen in personswithout diabetes (e.g., cardiovascular riskfocus, metabolic improvements, bodyweight/fat management), plus a few more.The increase in sensitivity to insulin (needingless insulin to get the same effect), decrease incardiovascular risk (lowering blood pressure,total cholesterol, increased HDL cholesterol)are common to both populations3. The effectof increased insulin sensitivity results in adecrease in the individual’s insulin require-ments. If the insulin intake is not decreased oradditional carbohydrates (glucose) are notingested, hypoglycemia may result either dur-ing the activity or in the hours following.

Exercise RecommendationsExercise recommendations for T1DM are

no different than those without Diabetes1.ACSM recommends aerobic exercise (contin-uous, rhythmic, prolonged activities using thelarge muscle groups of the arms and/or legs)three to five days per week, for 20 to 60 min-utes at 40 to 85 percent of heart rate reserveor 55 to 90 percent of heart rate maximum9.Resistance and flexibility training are recom-mended two to three days per week.

If the person with T1DM is over 35 yearsold, or is over 25 years old and has had dia-betes for more than 15 years, has any risk fac-tors for coronary heart disease, autonomicneuropathy, or any microvascular disease(proliferative retinopathy or nephropathy),he/she should undergo a medical evaluationbefore beginning an exercise program. This

will help ensure that he/she will not exacer-bate any preexisting complications by partici-pating in an exercise program2.

PrecautionsThere are certain precautions which are

helpful when advising an individual withT1DM on an exercise program. Always useadequate warm-up and cool-down periods; ifneuropathy is present, avoid high impactactivities; for weight bearing activities, wearfootwear which is properly fitted, supportiveand well cushioned; use proper hygiene, keep-ing feet dry and clean; and, most importantly,perform regular blood glucose monitoring.

To help regulate the glycemic response toexercise several steps can be taken.Remember, everyone is different, and,depending upon how long the individual hashad diabetes, how “tight” their glycemic con-trol, and how well they know their body’sresponse to a given exercise bout, to a certainquantity of insulin, to a certain quantity offood, some of these recommendations may ormay not be applicable2.1. Metabolic Control Before Exercise

–Avoid exercise if fasting glucose is>250mg/dl and ketosis is present

–Use caution if glucose is > 300 mg/dl andno ketosis is present

–Ingest added carbohydrate if glucose is <100 mg/dl

2. Blood glucose monitoring before and afterexercise–Identify when changes in insulin or foodintake are necessary

–Learn the glycemic response to differentexercise conditions

3. Food Intake–Consume added carbohydrate as neededto avoid hypoglycemia

–Carbohydrate-based foods should bereadily available during and after exercise

Use these guidelines to help individualswith T1DM develop a personal history ofhis/her response. The best way to do this is tomonitor blood glucose regularly and keep awritten record. Overall, it is the individual’sresponsibility! The use of an exercise diary isvery helpful. Record the blood glucose levels,the amount of insulin taken and when, time ofday of usual exercise, what did the last mealconsist of and when was it eaten, type of exer-cise and for how long, along with any specialcomments (i.e., blood sugar dropped threehours after exercise). The hope is that theindividual with T1DM will gain informationabout his or her response to different activitiesand conditions and can use that informationto plan meals and medications for upcomingactivities.

Hypoglycemia is most problematic inT1DM. Therefore, a record of the above men-tioned parameters can be used to modifyinsulin regimen. Examples of insulin dose

modifications are listed below4.1. Inject > one hour before exercise2. Decrease intermediate-acting insulin3. Omit short-acting insulin before exercise4. Decrease insulin pump setting when exer-

cising around meal times5. Inject insulin into “non-exercising” muscle-

abdominal is preferredThese modifications, along with the avail-

ability of additional carbohydrates (as need-ed), should decrease the probability of ahypoglycemic reaction. If you notice the signsof hypoglycemia (trembling, rapid heart rate,profuse sweating, pale skin, confusion or dis-orientation, and jumbled, slow or slurredspeech), give the individual some simple sugar.Many of these symptoms could just be due toa more intense exercise bout than usual, butwith a person with T1DM , better to be safethan sorry.

There is no reason why persons withT1DM should not be encouraged to partici-pate in regular exercise and gain the benefitsthat all individuals, with or without diabetes,receive from daily exercise. Though precau-tions must be taken, through trial and error,the person with T1DM can learn to adjusttheir insulin dose appropriately. Insulinadjustments and the availability of simple car-bohydrates will decrease the risk of a hypo-glycemic incident.

References1. American College of Sports Medicine: ACSM’s guidelines for

exercise testing and prescription, 7th ed. M.H. Whaley, P.H.Brubaker, R.M. Otto (eds). Philadelphia: Lippincott Williams &Wilkins, 2005.

2. American Diabetes Association: Clinical practice recommenda-tions 2000: diabetes mellitus and exercise. Diabetes Care 23(suppl 1):S50-S54, 2000.

3. Brooks, G.A., T.D. Fahey, and K.M. Baldwin. Exercise physiolo-gy: human bioenergetics and its applications. 4th ed. New York:McGraw-Hill, 2005.

4. Colberg, S.R. and D.P. Swain. Exercise and diabetes control: awinning combination. The Physician & Sports Medicine 28(4):63-64, 69-72, 77-78, 81, 2000

5. Defranco, S., S. Bonissoni, F. Cerutti, et al. Defective function ofFas in patients with type 1 diabetes associated with other autoim-mune diseases. Diabetes 50:483-488, 2001.

6. Devlin, J. Effects of exercise on insulin sensitivity in humans.Diabetes Care 15 (11):1690-1693, 1992.

7. Kitabchi, A. E., G. E. Umpierrez, M. B. Murphy, et al.Management of hyperglycemic crises in patients with diabetes.Diabetes Care 24:131-153, 2001.

8. National Institute of Diabetes and Digestive and Kidney Diseases.National Diabetes Statistics fact sheet: general information andnational estimates on diabetes in the United States, 2005.Bethesda, MD: U.S. Department of Health and Human Services,National Institute of Health, 2005.

9. Pollock, M.L., G.A. Gaesser, J.D. Butcher, et al. The recom-mended quantity and quality of exercise for developing andmaintaining cardiorespiratory and muscular fitness and flexibilityin healthy adults. Medicine & Science in Sports & Exercise30(6):975-991, 1998.

10. Todd J.A., J.I. Bell, H.O. McDevitt, et al. HLA-DQ beta genecontributes to susceptibility and resistance to insulin-dependentdiabetes mellitus. Nature 329:599-604, 1987.

11. Widermaier, E.P., H. Raff, and K.T. Strang. Vander’s humanphysiology: the mechanisms of body function. 10th ed. NewYork: McGraw-Hill, 2006.

12. Wolf, E., K.M. Spencer, A.G. Cudworth, et al. The genetic sus-ceptibility to type 1 (insulin-dependent) diabetes: analysis of theHLA-DR association. Diabetologia 24:224-230, 1983.

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Coaching News

GGeett oouutt ooffssaalleess aannddggoo ffiisshhiinngg!!

This is the sixteenth edition of the CoachingNews column, sponsored by WellcoachesCorporation in alliance with ACSM, and itappears regularly in ACSM’s Certified News.Our thanks to Robert Rhode, Ph.D., for thistitle used in his presentation, “CoachingBehavior Change Using MotivationalInterviewing,” at IHRSA 2007.

What would happen to your personal train-ing business if you stopped selling trainingand focused instead on helping your clientsclarify their goals, motivations, and the valueof becoming fit? Would your business witheror grow?

My money is on growth.I’m not suggesting that you stop charging

for your services or that there is somethingshameful about selling. I am suggesting that achange in perspective—from selling to fish-ing—will help your clients clarify why theywant to be fit and why they train with you. Asa result, your clients are more likely to beintrinsically motivated and, therefore, moresuccessful. They will also happily train withyou for longer periods of time.

So what is fishing and how do you do it?Let me answer this question through the

lens of Motivational Interviewing (MI), anevidence-based methodology for helping peo-ple change behavior. MI is “a client-centered,directive method for enhancing intrinsic moti-vation to change by exploring and resolvingambivalence.”1 Let’s explore this further.

First, MI’s focus is wholly on the client—his/her agenda, motivations, perspective. Topreserve this focus, it’s essential to fish forinformation beyond that needed to create anexercise prescription. Be curious and cultivatea beginner’s mind—no assumptions. Askquestions like, “What do you want to accom-plish?” “If your training is successful, whatwould be different for you a year from now?”“What motivates you and what gets in yourway?” These open-ended questions generatethoughtful responses and reveal things aboutyour clients that are important for you toknow and use.

Curiosity has another benefit as well. Itassumes that your clients have the answersand that these answers are correct. Your

clients are, after all, the experts of their ownlives and it’s important that you give them thefreedom to completely speak their mind with-out judgment.

What should you do when your client mis-understands the literature or chooses anaction based on a popular exercise or nutri-tion myth? There is, after all, no shortage of“diet du jour” and “fitness by celebrity” pro-grams. By all means, speak up if your clientschoose goals that are unrealistic or prescrip-tions not supported by exercise science. Beaware, however, that how you speak up willmake all the difference.

When your client asks you to endorsesomething unscientific, harmful, or ineffec-tive, go fishing. This is the perfect time to ask,“What do you like about the diet?” or, “Whatattracted you to this particular exercise pro-gram?” Questions like these respect yourclient’s intelligence, are non-threatening, andwill provide you with valuable informationabout your client’s agenda and motivations.

Once you have clarified what’s importantto your client, summarize the relevant infor-mation and ask permission to share yourexpertise: “Now that I know you don’t enjoycardio exercise, how do you feel about creat-ing a program that integrates shorter bouts ofaerobic training with strength training?” or “Iunderstand your reluctance to strength trainbecause you don’t want to develop bulkymuscles. May I share with you some of the sci-ence that speaks to that concern?” My clientsalways say, “yes” when I ask permission andI believe yours will as well.

Secondly, MI proposes that change occursnaturally and fishing gives you an effectiveway to encourage this natural human propen-sity. To do this, listen for “change talk.”Statements that begin with “I want to…” or“I can…” or “I started…” or “I will…” or “Ineed to…” give voice to your clients’ motiva-tions and intention to act. And when you hearchange talk, don’t just sit there! Reflect it backto your client, reinforce it by asking for moreinformation (“Tell me more…”). Go fishingand keep the lure dangling where your clientcan see it!

Reinforcing your clients’ change talk isimportant because “people are more persuad-ed by what they hear themselves say than bywhat someone tells them.”2 In other words,your clients will always be more motivated bywhat they say themselves than by what youtell them about your service or the promise ofexercise.

Third, MI assumes that ambivalence is anatural part of the change process. Therefore,don’t ignore or diminish your clients’ ambiva-lence when you hear it. Instead, embrace it—after all, change doesn’t happen without it.Help your clients resolve their ambivalence by

amplifying the discrepancy between theirpresent behavior and their goals. In otherwords, go fishing!

When your client misses a workout, ratherthan reminding them that they can’t achievetheir goals without putting in the time, sayinstead: “I’m curious. How did it feel to notcome to the club when you said you would?”or “What was great about giving yourself anunplanned day off from your workout?”These questions are neutral in tone, respectful,non-judgmental, and appreciate that the clienthas choice about doing or not doing thehealthy behavior. You can then ask, “Whatwould you do differently next time?” or“What did you learn?” Questions like thesehelp your clients clarify their motivations andreinforce their commitment to their goals.Both outcomes also strengthen the value ofthe work they do with you.

In summary, if you fish effectively you cansell less. You create for your clients a richertraining environment by encouraging them tohear their own change talk, explore theirgoals and motivations, and articulate forthemselves all they receive from your service.In short, fishing gives your clients a powerfulframework for success. And the greater yourclients’ success, the greater is your reward—personally and professionally. Go fishing!

About the AuthorHeidi Duskey, MA is ACSM Health/Fitness Instructor®

Certified and certified wellness coach and has worked inthe health club industry in management roles for the past15 years. Heidi coaches privately, and conducts groupcoaching programs in a variety of wellness topics andwalks the walk as a seasoned racewalker. Heidi can bereached at [email protected]

References1. Miller, William R., Rollnick, S. (2002). Motivational

Interviewing, Second Edition. New York: The Guilford Press.2. Bem, D.J. (1972). Self-perception theory. In L. Berkowitz (Ed.),

Advances in experimental psychology (Vol. 6, pp. 1-62). NewYork: Academic Press.

The Coaching News column is sponsored by WellcoachesCorporation, the leader in health, fitness, and wellness coach train-ing and delivery of wellness coaching services, in partnership withACSM. To learn more about this topic or other topics on coachinghealth, fitness, and wellness, visit www.wellcoach.com.

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The presence of Diabetes Mellitus presentsspecific challenges with regard to effectivemaintenance of normal or near normal bloodglucose levels before, during, and after physi-cal activity. Given the many health benefitsbestowed by exercise, though, it has been andcontinues to be an integral cornerstone of dia-betes management. Certain prescribed med-ications, including some oral hypoglycemicand other diabetic medications, can affect thebody’s metabolic response to exercise, howev-er, frequently causing hypoglycemia (a bloodglucose level of less than 70 mg/dl). In orderto help diabetic individuals engage in regularexercise with a minimal risk of such potential-ly negative metabolic changes, it is importantfor health and fitness professionals to gain abetter understanding of the actions of suchmedications and their potential glycemiceffects.

Oral Hypoglycemic and OtherDiabetic Medications

To date, there are Food and DrugAdministration (FDA) approved oral Diabetic

medications available in six different classes,along with three injectable ones (includinginsulin). Many oral drugs in the sulfonylureaclass (see Table 1) increase the risk of develop-ing hypoglycemia during and after a bout ofphysical activity. Older-generation sulfony-lureas (such as Diabinese and Orinase) causeinsulin release from the pancreas and some-what decrease insulin resistance; due to theirlonger duration of up to 72 hours, though,gives them a greater potential to cause individ-uals’ blood glucose levels to go too low duringand/or after any physical activity.13 Second-generation sulfonylureas, such as DiaBeta,Micronase, Glynase, Amaryl, and Glucotrol,generally are cleared from the body morequickly (in 24 hours or less) and thereby pres-ent a smaller risk of causing exercise-associat-ed hypoglycemia. Among these, DiaBeta,Micronase, and Glynase convey the greatestrisk due to their slightly longer duration (24hours versus only 12 to 16 hours for the othertwo).6 Individuals will need to check theirblood glucose levels more often when exercis-ing (and afterwards) if they take any of these

longer-lasting oral hypoglycemic medications.When exercise becomes regular, they may alsobenefit from checking with their health careproviders about lowering their doses, particu-larly if they are experiencing more frequentlows with exercise. For the most effectivedosage adjustments, diabetic exercisers shoulddocument all bouts of hypoglycemia after ver-ifying them with blood glucose monitoring.

Most of the medications in the remainingclasses, however, are far less likely to affectglycemic responses to exercise. For example,insulin sensitizers like Avandia and Actosmainly improve the action of insulin at rest,not during exercise, so their risk of causingexercise-associated hypoglycemia is almostnonexistent.10 Similarly, Glucophage andGlucophage XR (the extended release form ofmetformin) are unlikely to cause it becausetheir main action is to lower liver glucose out-put overnight, which has little effect on exer-cise responses.12 Prandin or Starlix usepotentially increases risk if taken immediatelybefore prolonged exercise as they increaseinsulin levels temporarily when taken beforemeals, and postprandial exercise in individu-als with Type 2 Diabetes Mellitus (T2DM)lowers blood glucose levels more than thesame bout done pre-breakfast (and beforeinsulin is released).9

Medications that slow down the absorptionof carbohydrates (Precose and Glyset) do notdirectly affect exercise, but can delay effectivetreatment of hypoglycemia during activitiesby slowing the absorption of carbohydratesingested to treat this condition. Finally, thenewest class of oral diabetic drugs, dipeptidylpeptidase-4 inhibitors (DPP-4 inhibitors),extend the action of insulin, but apparently donot increase the risk of exercise-induced hypo-glycemia in individuals with T2DM alreadybeing treated with metformin.1

Most of these oral medications are used byindividuals with T2DM, who commonly takea combination of two or more of them in anattempt to more effectively control glycemia.Certain medications themselves are alreadycombination drugs; for example, Glucovanceis comprised of glyburide and metformin.Some recent research, though, has additional-ly indicated the use of metformin in insulin-resistant individuals with Type 1 DiabetesMellitus (T1DM) who are experiencing aform of “double diabetes” with characteristicsof both types.4,7 Individuals with either typeof diabetes can certainly benefit from theinsulin-sensitizing effects of an acute bout ofexercise and regular physical training, both ofwhich improve insulin action and generallylower blood glucose levels.

There are also two new injectable diabeticmedications (listed in Table 1) that can be usedby individuals with either T1DM or T2DM:Byetta (exenatide, or extendin-4) and Symlin

Avoiding PossibleInteractions BetweenExercise and DiabeticMedicationsSheri R. Colberg, Ph.D., FACSM, ACSM Exercise Test Technologist® Certified, AssociateProfessor of Exercise Science, Exercise Science, Sport, Physical Education, and RecreationDepartment, Old Dominion University, Norfolk, Virginia

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(pramlintide), a synthetic form of amylin,which is a hormone normally co-released frompancreatic beta cells with insulin.5,11 The mainexercise-related concern with the use of thesemedications is that they both delay the empty-ing of food from the gut after a meal andcould, therefore, slow the release of ingestedcarbohydrates taken to prevent or treat lowblood glucose levels during a bout of exercise.Consequently, to err on the side of safety, ifhypoglycemia is likely to occur during physicalactivity, neither Byetta nor Symlin should beinjected within two hours prior to scheduledphysical activity.

Precautions for Insulin UseAlthough individuals with T1DM must

taken exogenous insulin, supplemental dosesare eventually prescribed for up to 40 percentof individuals with T2DM, making insulin usewidespread. Insulin users, particularly oneswith T1DM, face a potentially more compli-cated exercise-medication interaction becausethey must precisely balance insulin and bloodglucose levels to avoid both hypoglycemia andpossible elevations in glucose levels duringexercise.7 Longer duration exercise is morelikely to have a glucose-lowering effect (unlessinsulin is deficient and ketone levels are mod-erate or higher), but shorter bouts of intenseexercise, such as sprinting or heavingweightlifting, can also cause blood glucoselevels to rise from the release of exaggeratedamount of counterregulatory hormones likeepinephrine and glucagon. In spite of theadditional challenges involved, one of the beststrategies for optimizing management out-comes is to learn the effects of exercise oninsulin action and differing insulin regimenson glycemic control. Today, there are manymedical options and they are constantlyexpanding. The majority of T1DM insulinusers and some T2DM users requiring insulinchoose to utilize a combination of short- andlong-acting insulins (varying by time to peakaction and total duration) given two to four(or more) times daily.8 Others may receive acontinuous infusion of short-acting insulinthat follows a basal-bolus regimen by using aninsulin pump.3

The goal during exercise is to mimic themetabolic responses of non-diabetic individu-als. When no more than minimal (basal) lev-els of insulin are circulating in thebloodstream during exercise, normoglycemiawill be more effectively maintained. Giventhat both insulin and muscular contractionsevoke separate mechanisms that cause mus-cles to take up glucose from the bloodstream,they additively increase muscle glucose uptakeduring exercise. Consequently, the type ofinsulin taken and the timing of its use canhave a large effect on glycemic responses tophysical activity.2,3,7 The onset, peak and dura-

tion of various insulins are listed in Table 2. If an individual exercises when exogenous

insulin levels are peaking, the risk of hypo-glycemia is greatly increased, particularlywhen failing to compensate with reducedinsulin doses or consumption of additionalcarbohydrates.2 For instance, intermediate-acting N injected at breakfast will peakaround noon and exert its effects throughoutthe afternoon. If exercise is done after lunchwithout an increased carbohydrate intake atthe prior meal or lower morning dose of Nbeing given, blood glucose levels may decreasemore rapidly than at other times of day withlower circulating levels of insulin. Exercisedone within two hours of the administrationof a rapid-acting insulin analog will alsorequire appropriate compensation. Con-versely, if only Lantus or Levemir (both ofwhich provide basal insulin coverage for 12 to24 hours) are circulating during an activity,then hypoglycemia will be much less likely toresult.8 Likewise, insulin pump users can nor-malize their response to exercise by either dis-connecting their pumps or reducingprogrammed basal rates during physical activ-ity, both of which will lower circulatinginsulin levels closer to non-diabetic levels.3

Some pump users also decrease their basalrates before and/or after the activity, depend-ing on how long it lasts and on their individ-

ual blood glucose responses.

Medications to Control OtherRelated Health Problems

Besides taking medications for diabetescontrol, many individuals may also take oth-ers to control elevated blood lipids (especiallycholesterol levels), hypertension, and othercoexisting health problems. Most medica-tions taken for non-diabetic reasons will notaffect exercise glycemia or other responsesdirectly, with a few notable exceptions. Use ofa class of drugs to treat high cholesterol levelscalled “statins” for short (including Lipitor,Mevacor, Pravachol, Crestor, and Zocor) mayresult in unexplained muscle pain and weak-ness during physical activity, possibly by com-promising the muscles’ ability to generateenergy effectively.14 However, muscle crampsduring or after exercise, nocturnal cramping,and general fatigue all resolve after statin useis discontinued. If an individual taking a drugfrom this class experiences any of these symp-toms with exercise, he or she needs to consultwith a doctor about possibly switching toanother cholesterol-lowering medication.Moreover, any prescribed drugs taken toreduce body water levels (diuretics like Lasix,Microzide, Enduron, and Lozol) and improveblood pressure can lead to dehydration and

Class of Drug

Sulfonylureas

Thiazolidenediones“Glitazones”

Biguanides

Meglitinides/Phenylalanine derivatives

Alpha-Glucosidase Inhibitors

DPP-4 Inhibitors

Amylin (injected)Incretins (injected)

Brand Name (Generic Name)

Amaryl (glimepiride), DiaBeta,Micronase, and Glynase (glyburide orglibenclamide), Glucotrol (glipizide),Diabinese (chlorpropamide), Orinase(tolbutamide)

Avandia (rosiglitazone), Actos (pioglitazone)

Glucophage, Glucophage XR(metformin)

Prandin (repaglinide),Starlix (nateglinide)

Precose (acarbose),Glyset (miglitol)

Januvia (sitagliptin phosphate), Galvus(vildagliptin)

Symlin (pramlintide acetate)Byetta (exenatide)

Mechanism of Action(s)

Promote insulin secretion frompancreatic beta cells; some medicationsmay increase insulin sensitivity

Increase insulin sensitivity of peripheraltissues, primarily skeletal muscles

Decrease liver output of glucose whileincreasing liver and muscle insulinsensitivity; no direct effect on beta cells

Stimulate beta cells to increase insulinsecretion, but only for a very shortduration (unlike sulfonylureas)

Work in small intestines to slowdigestion of some carbohydrates tocontrol post-meal blood glucoseelevationsWork by inhibiting DPP-4, an enzymethat breaks down glucagon-like peptide-1 (GLP-1); delayed GLP-1 degradationextends insulin action whilesuppressing glucagon release

Helps control glycemic spikes for threehours after meals by delaying gastricemptying

Stimulate insulin release; inhibit theliver’s release of glucose by loweringpost-meal glucagon release; delaygastric emptying

Table 1: Classes of Oral and Other Diabetic Medications

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10ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

dizziness from hypotension, but will not like-ly affect blood glucose levels. Vasodilatorssuch as nitroglycerin increase coronary bloodflow during exercise, but can also induce lowblood pressure, which increases the risk offainting during or following an activity.Finally, beta-blockers (e.g., Lopressor, Inderal,Levatol, Corgard, Tenormin, Zebeta, and oth-ers) taken to treat heart disease and hyperten-sion lower resting and exercise heart rates.For individuals using such a blocker, theirheart rates will not reach age-expected valuesat any intensity of exercise.15

On the other hand, if taking either ACEinhibitors (Capoten, Accupril, Vasotec,Lotensin, Zestril, etc.) or angiotensin II recep-tor blockers (ARBs, such as Cozaar, Benicar,and Avapro), which are commonly prescribedfor diabetic individuals to reduce blood pres-sure and/or protect the kidneys, individualscan expect no negative metabolic effects dur-ing exercise. In fact, using certain ACEinhibitors may actually lower the risk of unto-ward cardiovascular events for anyone withpre-existing heart disease. Other medicationstaken to treat heart disease and hypertension(calcium-channel blockers like Procardia,Sular, Cardene, Cardizem, and Norvasc),depression (Wellbutrin, Prozac, and others),or chronic pain (Celebrex) also have noimpact on exercise responses. Aspirin andother blood thinners (such as Coumadin),however, have the potential to make individu-als bruise more easily or extensively inresponse to athletic injuries.

ConclusionClearly, the use of various medications to

control diabetes (and related health problems)can affect glycemic and other responses toexercise. In order to engage safely in regularphysical activity without fear of unbalancingblood glucose levels, persons with diabetesmust be willing to check their blood glucose atmore frequent intervals than normal to deter-mine their unique metabolic responses andany potential interactions with their pre-scribed medications. To help them do so,health and fitness professionals need to beaware of these possible effects and prescribeand monitor exercise appropriately.

Recommended Review Articles and Resources:• Albright, A., M. Franz, G. Hornsby, A. Kriska, D. Marrero, I.

Ulrich, and L.S. Verity. American College of Sports Medicine.American College of Sports Medicine position stand. Exercise andtype 2 diabetes. Medicine & Science in Sports & Exercise,32:1345?1360, 2000.

• Colberg, S. The Diabetic Athlete: Prescriptions for Exercise andSports. Champaigne, IL: Human Kinetics, 2001.

• Sigal, R., G. Kenny, D. Wasserman, et al. Physical activity/exerciseand type 2 diabetes: a consensus statement from the AmericanDiabetes Association. Diabetes Care, 29(6):1433-1438, 2006.

References1. Charbonnel, B., A. Karasik, J. Liu, et al. Efficacy and safety of

the dipeptidyl peptidase-4 inhibitor sitagliptin added to ongoingmetformin therapy in patients with type 2 diabetes inadequately

controlled with metformin alone. Diabetes Care, 29(12):2638-2643, 2006.

2. Chokkalingam, K., K. Tsintzas, L. Norton, et al. Exercise underhyperinsulinaemic conditions increases whole-body glucose dis-posal without affecting muscle glycogen utilisation in type 1 dia-betes. Diabetologia, 50(2):414-421, 2007.

3. Diabetes Research in Children Network (DirecNet) Study Group;E. Tsalikian, C. Kollman, et al. Prevention of hypoglycemia dur-ing exercise in children with type 1 diabetes by suspending basalinsulin. Diabetes Care, 29(10):2200-2204, 2006.

4. Hamilton, J., E. Cummings, V. Zdravkovic, et al. Metformin asan adjunct therapy in adolescents with type 1 diabetes andinsulin resistance: a randomized controlled trial. Diabetes Care,26(1):138-143, 2003.

5. Joy, S., P. Rodgers, A. Scates. Incretin mimetics as emerging treat-ment for type 2 diabetes. Annals of Pharmacotherapy,39(1):110–118, 2005.

6. Larsen, J., F. Dela, S. Madsbad, et al. Interaction of sulfonylureasand exercise on glucose homeostasis in type 2 diabetic patients.Diabetes Care, 22(10):1647–1654, 1999.

7. Muis, M., M. Bots, H. Bilo, et al. Determinants of daily insulinuse in type 1 diabetes. Journal of Diabetes and Its Complications,20(6):356-360, 2006.

8. Peterson, G. Intermediate and long-acting insulins: a review ofNPH insulin, insulin glargine and insulin detemir. CurrentMedical Research and Opinion, 22(12):2613-2619, 2006.

9. Poirier, P., S. Mawhinney, L. Grondin, et al. Prior meal enhancesthe plasma glucose lowering effect of exercise in type 2 diabetes.Medicine & Science in Sports & Exercise, 33:1259–1264, 2001.

10. Reusch, J., J. Regensteiner, P. Watson. Novel actions of thiazo-lidinediones on vascular function and exercise capacity.American Journal of Medicine, 115:69S–74S, 2003.

11. Ryan, G., L. Jobe, R. Martin. Pramlintide in the treatment oftype 1 and type 2 diabetes mellitus. Clinical Therapeutics,27(10):1500-1512, 2005.

12. Schwartz, S., V. Fonseca, B. Berner, et al. Efficacy, tolerability,and safety of a novel once-daily extended-release metformin inpatients with type 2 diabetes. Diabetes Care, 29(4):759-764,2006.

13. Shorr, R., W. Ray, J. Daugherty, et al. Individual sulfonylureasand serious hypoglycemia in older people. Journal of theAmerican Geriatrics Society, 44(7):751-755, 1996.

14. Thompson, P., P. Clarkson, R. Karas. Statin-associated myopa-thy. Journal of the American Medical Association,289(13):1681-1690, 2003.

15. Wonisch, M., P. Hofmann, F. Fruhwald, et al. Influence of beta-blocker use on percentage of target heart rate exercise prescrip-tion. European Journal of Cardiovascular Prevention andRehabilitation, 10(4):296-301, 2003.

About the Author:Sheri R. Colberg, Ph.D., FACSM, is an associate professor

of exercise science at Old Dominion University in Norfolk,Virginia. As well as being an American DiabetesAssociation-funded clinical exercise researcher, she is alsothe author of numerous articles and four books on diabetesand exercise, including The Diabetic Athlete (2001), The 7Step Diabetes Fitness Plan (2006), and 50 Secrets of theLongest Living People with Diabetes (November 2007).

Staying up to date with theACSM Calendar of Events

Whether it’s upcoming dates, home study

opportunities, or upcoming conferences, you will

find the latest continuing education information

in the ACSM Calendar of Events at

www.acsm.org/coe. Calendar entries include

conferences endorsed by ACSM that offer

continuing education credits, as well as general

non-ACSM approved programs that have been

submitted to our office. If you would like to

have your meeting reviewed for endorsement,

select “Endorsement Application” to access the

Guidelines for Endorsement and Continuing

Education Credit application. For questions on

ACSM continuing education opportunities, the

ACSM endorsement process, or to receive the

monthly calendar of events e-mail, please

contact the education department at

[email protected]. For questions on non-

ACSM endorsed continuing education that

could be accepted for recertification, please

contact Traci Rush at [email protected].

Diabetic Medications... Continued from Page 9

Page 11: ACSM Diabetes

11JULY/AUGUST/SEPTEMBER 2007 | VOLUME 17; ISSUE 3 ACSM’s Certified News

SELF-TEST #1 (1 CEC): The following questions weretaken from “Overview of Type 2 Diabetes” published inthis issue of ACSM’s Certified News, pages 3-4.

1. For type 2 diabetics, the risk for a fatal heart attack orstroke is increased by over nondiabetics.

A. 1-2 timesB. 3-5 timesC. 2-4 timesD. 2-3 times

2. Type 2 diabetics only need to monitor their bloodglucose before exercising, while recovery and post-exercise is not as important.

A. TrueB. False

3. Current recommended aerobic exercise at a moderateintensity for type 2 diabetes does NOT include _______:

A. 3-7 days per weekB. At least 90 minutes per weekC. 40-60% HRD. At least 150 minutes per week

4. Type 2 diabetes can be effectively treated throughweight loss, nutrition modifications, and physical activity.

A. TrueB. False

5. An important tool used to determine long-termglucose control for diabetes is ____________:

A. A fasting blood glucoseB. A post-absorptive blood glucoseC. Glycosylated hemoglobin (A1C)D. All of the above

SELF-TEST #2 (1 CEC): The following questions weretaken from “Type 1 Diabetes and Exercise” published inthis issue of ACSM’s Certified News, pages 5-6.

1. Type 1 diabetes is the most prevalent form of diabetesin the United States.

A. TrueB. False

2.Type 1 diabetes is most commonly seen inA. African AmericansB. Obese individualsC. Individuals over the age of 45D. Individuals who inherit HLA alleles DR3 or DR4E. A, B, and C only

3. A person with diabetes suffering from ketoacidosishas

A. High blood glucoseB. High circulating levels of acetoacetic and ‚-hydroxybutyric acidsC. High blood pHD. A and B onlyE. All of the above

4. The biggest concern for a person with type 1 diabetesparticipating in an exercise program is

A. HypoglycemiaB. Diabetic comaC. HyperglycemiaD. Improper heart rate responseE. Inadequate sweat response

5. Testing and recording blood glucose levels before andafter exercise is good practice for the novice exerciserwith type 1 diabetes. He/She should also

A. Note when and how much insulin was takenB. Note when the last meal was eaten, and thecomposition of the mealC. Time of day the exercise was performedD. Type, intensity and duration of the exerciseE. All of the above

SELF-TEST #3 (2 CEC): The following questions weretaken from “Avoiding Possible Interactions BetweenExercise and Diabetic Medications” published in this issueof ACSM’s Certified News, pages 8-10.1. Certain prescribed medications, including some oralhypoglycemic and other diabetic medications, can affectthe body’s metabolic response to exercise, frequentlycausing hypoglycemia.

A. TrueB. False

2. Insulin sensitizers like Avandia and Actos mainlyimprove the action of insulin at rest, not during exercise,so they’re unlikely to cause exercise-associatedhypoglycemia.

A. TrueB. False

3. Which of the following diabetic medications has thegreatest potential to cause hypoglycemia during or afterphysical activity?

A. ActosB. DPP-4 inhibitors, like JanuviaC. GlucophageD. GlysetE. Insulin

4. What is the main concern with the use of eitherSymlin or Byetta within two hours prior to exercise?

A. The injection site used to give either one might stillhurt during exercise.B. If hypoglycemia develops during exercise, it maybe harder to treat rapidly.C. They are so new to the market that no one knowstheir exact mechanisms of action.D. Both cause the release of insulin that could causehypoglycemia during exercise.E. Due to their action, blood glucose levels will likelyrise during exercise.

5. Which type of insulin administered two hours beforethe start of exercise is most likely to result inhypoglycemia due to its onset and peak times?

A. LantusB. N (NPH)C. Basal insulinD. Humalog or NovoLogE. None of these insulins

July-September 2007 Continuing Education Self-TestsCredits provided by the American College of Sports Medicine • CEC Credit Offering Expires September 30, 2008

To receive credit, circle the best answer for each question, check your answers against the answer key on page 2, and mailentire page with check or money order payable in US dollars to: American College of Sports Medicine, Dept 6022, Carol Stream, IL 60122-6022

ACSM Member (PLEASE MARK BELOW) Please Allow 4-6 weeks for processing of CECs[ ] Yes-$15 TOTAL $_________________[ ] No- $20 ($25 fee for returned checks)ID # __________________ (Please provide your ACSM ID number)

PLEASE PRINT OR TYPE REQUESTED INFORMATION

NAME

ADDRESS

CITY STATE ZIP

BUSINESS TELEPHONE E-MAIL

July-September 2007 Issue EXPIRATION DATE: 09/30/08SELF-TESTS SUBMITTED AFTER THE EXPIRATION DATE WILL NOT BE ACCEPTED.Federal Tax ID number 23-6390952

Tip: Frequent self-test participants canfind their ACSM ID number located onany credit verification letter.

ACSM’s

CertifiedNews® ACSM USE:

627826

Page 12: ACSM Diabetes

12ACSM’s Certified News AMERICAN COLLEGE OF SPORTS MEDICINE | (317) 637-9200

ACSM’s Certified News ISSN # 1056-9677P.O. Box 1440Indianapolis, IN 46206-1440 USA

ACSM’s Regional ChaptersEnjoy top-notch educational presentations

and unmatched opportunities to network withfellow professionals at ACSM’s RegionalChapter meetings. In addition, earn valuablecontinuing education credits to keep yourcertification current. Below is a listing ofupcoming meetings near you:• July 18-21, 2007,Alaska Chapter, Sitka,AK

Contact: Litia Garrison,[email protected], (907) 747-5160

• October 4-5, 2007, Northland Chapter,Brookings, SDContact: John Keener, Ph.D.,[email protected], (218) 726-8531,www.d.umn.edu/~nacsm

• October 18-19, 2007, Central StatesChapter, Springfield, MOContact: Joel Cramer, Ph.D., [email protected],(405) 325-1371, www.centralstatesacsm.org

• October 25-27, 2007, Midwest Chapter,Columbus, OHContact:Tim Kirby, Ph.D., [email protected],(614) 292-0664, www.mwacsm.org

• November 2-3, 2007- Mid-Atlantic Chapter,Harrisburg, PAContact:W. Craig Stevens, Ph.D., FACSM,[email protected], (610) 738-0497,www.marcacsm.org

• November 9-10, 2007, Southwest Chapter,San Diego, CAContact: Jack Young, Ph.D., FACSM,[email protected], (702) 895-4626,www.swacsm.org

• November 15-16, 2007, New EnglandChapter, Providence, RIContact: NEACSM Office, [email protected],(860) 224-5888, www.neacsm.org

• Completed a Pre-workshop Packet andStudy Guide for ACSM Health/FitnessInstructor® 2007 workshops

• Established an Exam Development Team(started at Annual Meeting last year)

Launched Item Writing Webinars• Launched the ACSM Certified Personal

TrainerSM Exam in Spanish – Available inJune

• Deployed an ACSM Membership DiscountFor non-member, ACSM CertifiedProfessionalsOur 70+ subject matter experts that com-

prise the CCRB are volunteers, and they willbe as busy as ever in the coming year. Pleasehelp us acknowledge their commitment andhard work with a special “thank you.”

Another important function of our annualupdates is to disseminate the activity and per-formance of all our certification programs.Please find the details in the table below,

“CCRB Examination Activity: January 1,2006 – December 31, 2006.”

Also, if you haven’t noticed already, eachissue of ACSM’s Certified News is nowthemed. In other words, each issue is specifi-cally devoted to a single and relevant topic forthe health/fitness practitioner. Plus, all CEC’savailable in each issue are now based exclu-sively on the articles that appear. This makesit easier than ever to accumulate yourrequired CECs to not only maintain your cer-tification status, but continue to develop yourknowledge base.

Finally, as a reminder for all of you whoserecertification window closes on December31, 2007: You should submit your accumulat-ed CEC’s (continuing education credits) andaccompanying fees as soon as possible, toavoid the last-minute rush as the end of theyear approaches. If you have any questionsabout your recertification status, please con-tact Traci Rush, ACSM’s CertificationManager, at (317) 637-9200, ext. 126.

News You Need... Continued from Page 1

CCRB Examination Activity:January 1, 2006 – December 31, 2006

Number of Number ofTotal Operational ExperimentalCandidates Pass Credentials (Scored) (Non-scored) Total Time

Credential (2006) Rate Awarded Items Items Items Limit

ACSM Certified 1,889 69% 1,303 125-150 0-25 125-150 2.5 hoursPersonal Trainer

ACSM Health/Fitness 874 67% 585 125-150 0-25 125-150 3.5 hours Instructor

ACSM Exercise 280 53% 148 100-135 0-25 100-135 3.5 hours Specialist

ACSM Registered 190 86% 163 125-150 0-25 125-150 3 hours ClinicalExercisePhysiologist