Chapter 6

Putting Your Plan Together

It is now time to take what you have learned from the previous chapters and put your action plan together. In this chapter I give you sample plans that will help you create your own exercise and diet plans. When you are creating your plan, keep in mind that you need to choose activities and foods that you enjoy and that allow you to be successful in your action plan. Remember to chart your progress, as discussed in chapter 3. Also in this chapter you will learn how to measure or estimate your physical fitness level, which you can use to keep track of your success. Your overall fitness level directly correlates to improved overall health.

Determining Where to Start

After receiving clearance from your doctor to exercise, you need to know your general fitness level so that you can choose activity plans that will work for you. If you have not been exercising regularly, then assume your fitness level is low. In this case you will want to make your transition into exercising as easy as possible by not concerning yourself with estimating your fitness level or measuring your heart rate. But as you reach the point where you are exercising at least 30 minutes a day, I encourage you to use some of the tools described in this chapter to refine your action plan and monitor your success.

As discussed in chapter 4, you will need to choose the mode, intensity, duration, frequency, and progression of your exercise program. This may seem complicated, but recognizing that these elements are essential to any exercise plan will make your endeavor much easier. You may choose to write your plan out formally as I do in the examples in this chapter, or you may decide just to keep track of what type of activity you are doing and how you are responding. The bottom line is to start exercising safely, monitor your progress, and respond appropriately to change.

Once you have chosen the type of exercise that you will do, select the level of intensity based on your estimated baseline fitness level. If you are just starting an exercise program or have been exercising up to a moderate intensity, you can do an in-home test called the three-minute step test (see next page) to estimate how much intensity you are able to endure (endurance level). If you have a low fitness level, choose an exercise with a metabolic equivalent (MET) of less than 6, such as walking. If you are at a moderate or high fitness level, you should select exercises with a MET above 6. (See pages 52-53 for more exercises and their corresponding METs.)

If you think that you already have a high level of fitness, you should have your testing done by a professional trained in fitness testing. In-home testing is less accurate when your fitness level is high. Typically your local fitness center employs a certified athletic trainer who can help you with this kind of testing. These more sophisticated and intensive cardiorespiratory tests and other types of testing (such as strength and flexibility) are beyond the scope of this book, but you can find many references in health and fitness books or on the Internet. Remember that you do not have to test your fitness level to start an aerobic exercise plan. Just start out at a pace that you can easily tolerate. Then work your way up as your fitness level increases, and add in strength and flexibility exercises.

Estimating Your Baseline Fitness Level

If you are currently not physically active, you should start with an exercise program that’s of low intensity, duration, and frequency. It should also be progressive, such as walking at a comfortable pace and increasing over time to a brisk walk. That is, the MET level should start around 4 (easy walking) and progress to 6 (brisk walking). If you are in the low-fitness group, we discuss an easy way to start exercising effectively right away. If you and your health care team decide that it is fine for you to do a fitness test at home, you should use the three-minute step test to guide you in determining the intensity of your exercise program and in measuring your progress toward your goals. If your physician orders an exercise stress test, you should ask to receive your fitness level (which is a measure of your oxygen consumption, usually written as VO₂max).

The in-home test is much less scientific and has not been extensively studied in the diabetic population. Therefore it is less accurate than those fitness tests performed by professionals. Nonetheless, it can be a convenient and useful tool for you to use in your action plan.

When you are just starting to exercise on a regular basis, you can find your ideal intensity by calculating your maximal heart rate (220 minus your age) and then calculating your low-intensity heart rate, which is roughly 60 percent of your maximal heart rate. To find out what your target heart rate is at a certain intensity, follow the procedures described on page 49 of chapter 4.

After warming up, start your chosen exercise at a slow pace. Exercise at a comfortable pace. Remember, if you have not exercised recently, you should start at a low level of intensity (50 to 60 percent). A good rule to follow is to exercise at a level that allows you to have a conversation while working out. At the end of five minutes stop and take your pulse rate as described in chapter 4. If your pulse rate is near your target, then remember how this intensity feels and maintain the pace. If you are below your target rate and feel that you can increase your intensity, do so until you reach your target heart rate.

Three-Minute Step Test

This test estimates your cardiorespiratory fitness level. After going through the test, find out where you are on the fitness scale (table 6.1). You can use this test to measure your progress; as your fitness improves your three-minute heart rate will decrease.

Equipment

You will need a 12-inch step (typical house steps) and a stopwatch or watch with a second hand.

Procedure

1. Start the test by standing on the level floor facing the step. Step up with one foot, followed by the other foot; then step down with the first foot, followed by the other foot. Continue doing this in an “up, up, down, down” fashion for three minutes.

2. When three minutes have passed, stop and take your pulse and compare it to the fitness scale in table 6.1.

Sample Action Plan

The following is an example of a typical action plan that I have developed for patients who have not been doing regular exercise. If you are already doing regular exercise, see the section at the end of this chapter for an example of a more advanced exercise program. However, you can still use the same approach to creating your action plan.

Kathy is a 35-year-old elementary school teacher with recently diagnosed type 2 diabetes but no current symptoms. She has not been physically active since high school and has gained a significant amount of weight. She has tried several different diet plans, none of which she has been able to stick with. Currently she adheres to no specific diet or exercise plan. Kathy has a good base of knowledge of her diabetes and would like to create an action plan to reduce her health risks and become a thriving and energetic person. She would like to remain medication free, if possible. The following is Kathy’s medical profile:

Age: 35 years

Smoker: No

Weight: 192 pounds (long-term goal is 152 pounds or less)

Height: 5 feet, 7 inches

BMI: 30 (long-term goal is 24 or less)

Blood pressure: 140/85 mmHg (ideal blood pressure is 130/80 mmHg)

Fasting glucose: 145 mg/dl (ideal level is 110 mg/dl or less)

HbA_1C: 8.5 (ideal is 7)

Lipids: Total cholesterol is 220 mg/dl (goal is less than 200 mg/dl); LDL is 115 (goal is less than 100 mg/dl); HDL is 40 (goal is more than 55 mg/dl); triglycerides are 220 (goal is less than 150 mg/dl)

Kathy is not a smoker, which puts her at significantly less risk for many other diabetic complications than if she were a smoker. Her BMI indicates that she is obese. Her blood pressure, blood glucose, and HbA_1C are all elevated. Her blood lipid profile is also abnormal. Kathy can improve all her health conditions by starting an exercise program and monitoring her food intake. In fact, she has a good chance of normalizing her medical profile without medication, as she desires, if she adopts a lifestyle that includes exercise and proper diet over the long term.

Kathy’s dietitian instructed her to eat a low-fat 1,700-calorie diet. She talked with her dietitian about ways to reduce sugar and fat in her home-cooked meals. Kathy enjoys cooking, so she purchased a cookbook with recipes for people with diabetes. (Many cookbooks for those with special dietary restrictions are available in bookstores and on the Internet. If you would like to experiment with your own recipes, a general rule is to reduce the carbohydrate and fat down to around one-third to one-half of the original recommended amount.)

Kathy’s Action Plan: Low to Intermediate Fitness Level

Diet Plan

Kathy’s current diet is estimated at 2,000 calories per day. After she consulted with her dietitian, her diet was reduced to 1,700 calories. As her BMI decreases and her exercise frequency or intensity increases, her required daily intake of calories will also increase to maintain energy balance.

Exercise Plan

Kathy enjoys walking but would like to start running eventually and possibly compete in a local 5K run. She has not exercised with any consistency for many years and has no other medical problems that would require the need for cardiovascular stress testing before she starts an exercise program.

Mode: Walking

Intensity: 60 to 80 percent of her maximal heart rate (220 – 35 = 185 maximal heart rate; 60 to 80 percent = 111 to 148 beats per minute). She will start at a comfortable pace where she is able to walk and talk with minimal difficulty. (See the section on progression.)

Duration: She will start with 10 minutes per session 2 to 3 times per day (20 to 30 minutes per day). (See the section on progression.)

Frequency: She will start with 1 to 4 days of exercise per week. (See the section on progression.)

Progression: Over the first 4 to 6 weeks, she may start jogging if she feels comfortable, and she will gradually increase her intensity to 80 percent of her maximal heart rate. She can also increase her duration from 30-minute sessions to 60-minute sessions; she may split these up into more convenient sessions as well. She may increase her frequency from 4 to 7 days per week. Kathy will likely meet her goal of running in a 5K race in the first 2 to 3 months.

Resistance exercise: Endurance strength building 3 days per week (two to three sets of 8 to 12 repetitions without significant strain or pain). Kathy will do biceps curls, triceps presses, chest presses, and shoulder shrugs starting at 5 pounds and increasing as tolerated. She’ll do leg curls and leg presses starting at 25 pounds and progressing as tolerated. (See chapter 4 for more about resistance exercises.)

Stretching: She’ll stretch the large muscle groups (focusing on the quadriceps, hamstrings, and calf muscles) before every aerobic exercising event; she’ll hold each stretch position to the point of mild discomfort for 10 to 30 seconds and repeat 3 to 5 times. (See chapter 4 for more about stretching and flexibility.)

Special motivator: The personal goal that will keep Kathy motivated is to compete in a 5K race.

Energy Balance

Kathy will keep a negative energy balance until she reaches her ultimate weight goal of around 152 pounds. Her initial goal will be to decrease her weight by 5 to 7 percent (about 10 pounds) by working up to losing approximately 1 pound per week. As discussed in an earlier chapter, 1 pound is approximately 3,500 calories. So Kathy needs to create a negative energy balance of 3,500. Let’s calculate how much exercise she will have to do to create a negative energy balance of 3,500 calories per week, assuming that her 1,700-calorie diet without exercise would put her in a neutral energy balance (keeping her weight stable).

Weekly caloric goal is 3,500 calories per week.

Body weight is 192 pounds (87.1 kilograms).

MET level is 6 (walking).

Calculation: To meet her goal, Kathy will need to burn 9.14 calories per minute to meet her goal; the calculation is 6 × 3.5 × 87.1 ÷ 200 = 9.14. And 3,500 calories per week divided by 9.14 calories per minute gives her the number of minutes she needs to exercise per week, which is 382. To find out the number of minutes per day, she needs to take the number of days per week that she plans on exercising, which is 4 to 7. So we take 382 minutes per week and divide it by the number of days per week of exercise sessions. To meet her weight-loss goal (negative calorie balance), she will need to work her way up to walking 96 minutes (1 hour, 36 minutes) per day, 4 days a week or 55 minutes per day, 7 days a week. When she reaches the point when she is able to do more intense exercising, such as running, she will have shorter durations of exercise that will help her meet her goal. She will also burn more calories as she starts to do strengthening exercises, which can also be calculated by using the MET units for those types of activities. In addition, she can decrease her caloric intake by 250 calories and cut her exercise in half to achieve the same weight-loss goal. You can experiment with these types of calculations for different types of exercise and caloric intakes.

Remember that you do not have to do as much exercise as shown in Kathy’s plan to see a positive change in your health. Also recognize that as her exercise level increases, she will have to increase her caloric intake for her weight-loss rate to remain stable. If she did not increase her food intake, her weight-loss rate would increase, and vice versa in accordance with the principle of energy balance. Finding this balance is the challenge here. This is where keeping your action plan log book up to date can be helpful to you. Charting your meals, your exercise, and your response (weight and glucose level changes) will allow you to see positive and negative trends in your plan.

Advanced Exercise Plans for Walking, Jogging, Biking, and Swimming

You can stick to one type of exercise, or you can mix up exercises during the week. I have found that mixing up the exercises makes my weeks more interesting. For instance, say you choose to jog for your aerobic exercise, and once you think you are in pretty good shape (that is, exercising at 75 to 80 percent of your maximal heart rate), try using one of the other types of exercises in place of jogging. You may even wish to use three different types of exercise. I have found swimming, biking, and jogging to be fun.

An action plan can include whatever type of exercise you enjoy or have available. Many options exist, such as cycling classes at a local fitness facility.

Walking

Frequency: 5 to 7 days per week.

Duration: 30 to 50 minutes per day.

Intensity: 75 to 80 percent of your maximal heart rate.

Progression: See the following table.

Jogging

Frequency: 5 to 7 days per week.

Duration: 20 to 50 minutes per day.

Intensity: 65 to 85 percent of your maximal heart rate.

Progression: See the following table.

Swimming

Frequency: 3 to 5 days per week.

Duration: 30 to 60 minutes per day of continuous swimming if you are currently a swimmer, or you can break it up into intervals that you can do easily and work your way up until you can complete the session continuously.

Intensity: 60 to 80 percent of your maximal heart rate. Note that your heart rate will be lower than normal when swimming. With swimming, it has been suggested that you subtract 13 beats per minute from your estimated maximal heart rate before calculating your training heart rate (McArdle et al. 2000).

Progression: See the following table.

Biking

Frequency: 5 to 7 days per week.

Duration: 30 to 60 minutes per day.

Intensity: 60 to 80 percent of your maximal heart rate.

Progression: See the following table.

Action Plan:

Putting Your Plan Together

• Determine your baseline fitness level either through a stress test from your doctor or an in-home test called the three-minute step test.

• Find your ideal intensity by calculating your maximal heart rate, and then calculating your low-intensity heart rate.

• Explore all exercise options in your area, including walking, running, cycling, and swimming, as well as group classes and membership at local fitness facilities.

• Use Kathy’s sample action plan as a guide to customizing your own program. You’ll have to adjust the specific elements based on your own preferences, needs, and levels.