By Serena Agusto-Cox | News & Views

According to the World Health Organization, the number of people living with diabetes rose to 830 million in 2022 from 200 million in 1990. However, fewer than 50% take medication to manage the disease. Many patients with diabetes who are eligible for cardiac and pulmonary rehabilitation (CR/PR) programs do not start or complete the prescription, even though their diabetes and cardiovascular diseases are interconnected. The CR/PR setting is an opportunity for health care providers to identify patients at risk for diabetes, provide self-care education about diabetes management, and meet patients where they are in their CR/PR recovery process without worsening their diabetes.

Understand Basic Diabetes Care

Michael See, MS, CDCES, ACSM-CEP, NBC-HWC, a certified diabetes care and education specialist, clinical exercise physiologist, board certified health and wellness coach, and consultant with Emergo, believes that CR/PR programs should view diabetes management and care as part of their overall rehabilitation strategy. He says, “Knowing the different types of diabetes and treatment methods can ensure CR/PR does not result in hypoglycemia or other issues for their patients. It also provides them with an opportunity to meet their patients’ education and self-care needs.” He also recommends becoming familiar with the American Diabetes Association’s Standards of Care in Diabetes.

“Diabetes is prevalent in many cardiovascular and pulmonary disease patients, and CR/PR professionals should have a grasp of the basic principles and practices around diabetes management,” he explains. Not only should CR/PR professionals have a fundamental understanding of diabetes management, they also should have basic knowledge of the latest continuous glucose monitoring (CGM) systems and how insulin delivery devices work to manage diabetes. “These insulin delivery devices are becoming more prevalent,” See notes.

In addition to learning the basics of best practices, CR/PR professionals also should look for ways to collaborate with endocrinologists, diabetes care education providers, and primary care physicians to meet the needs of their patients. For example, CR/PR staff can collaborate with the patient’s diabetes care team to utilize information from a CGM to adjust insulin or other medications during exercise.

Learn About the Patient’s Relationship With Diabetes

Beyond learning the basics of diabetes care and management, CR/PR staff also should engage patients in questionnaires to assess their relationship with the disease. Are they someone who has lived with diabetes for a decade or more? Are they newly diagnosed? Do they manage their diet and exercise or check their glucose levels regularly? These are all questions that could be answered by an assessment. “Diabetes is a 24/7, 365-day condition,” See explains. “And to provide these patients with the best CR/PR care, staff should determine if a patient is distant from their condition or if they are intimately involved in its management.”

Learning this information upfront will help CR/PR professionals determine how much education a patient wants or needs about diabetes care management during their  program. See points out, “In many cases, people with diabetes who are engaged with insulin therapy are reluctant to enroll in CR/PR programs because they know that exercise can adversely impact their glycemic control. In other cases, some may have diabetes-related complications that make exercise harder, including neuropathy and retinopathy. These conditions make them very cautious.”

Power of Mindfulness

Patients with diabetes who balk at entering a CR/PR program require special attention. “The CR/PR settings need to be mindful that these people can be reluctant to enroll in programs,” warns See. “The survey or assessment can help staff understand each patient’s motivations for enrollment as well as their fears about exercise. Even if it isn’t a formal questionnaire, See adds, “It can be a short conversation: ‘Tell me about your relationship with your diabetes’ or ‘what do you think your biggest challenge will be?’ or ‘what do you want to celebrate at the end of this program?’”

When a patient is talking about their fears of hypoglycemia and being unable to manage it, CR/PR staff should take that opportunity to partner with them and their health care team on how to handle those moments. Education on diet and what to eat before exercise can also provide some guideposts for these patients, according to See.

For instance, if a patient comes to CR/PR after having a bowl of cereal and a glass of orange juice and taking metformin, their starting blood sugar may be 140 but spike to 250 an hour later. “This is a teaching opportunity,” See says. “CR/PR professionals can then ask what they ate for breakfast that could spike their glucose levels. They can explain that 80 grams of refined carbohydrates can be broken down quickly by the body. They can offer alternative breakfast options for next time, such as having a slice of toast with peanut butter and a Greek yogurt. That’s about 30 grams of carbohydrates and some protein.”

Some patients may need support to make informed decisions regarding optimal blood glucose levels before and after exercise, which is where a basic understanding of diabetes care and management is essential.

Medication Complications Impact CR/PR Care

CR/PR staff also need to be aware of what medications are used by their enrollees. “The risk of hypoglycemia during exercise is a real concern for patients and staff,” says See. “Being able to recognize the symptoms, including excessive sweating, rapid heartbeat, and problems processing, can ensure that patients with diabetes do not have an adverse event in CR/PR.” Those patients without a CGM may not be as aware of pending low blood sugar.

Some types of insulin therapies leave patients vulnerable to hypoglycemia when exercising while other medications, like metformin, work primarily through the liver. For PR patients who have chronic obstructive pulmonary disease (COPD), many have steroid therapies, which See explains can cause marked elevations in blood sugar levels during exercise. “Many of these people who are on these therapies for COPD and related pulmonary conditions may find themselves at a greater risk of diabetes,” he adds.

He urges CR/PR staff to be aware of newer diabetes treatments and how they impact patients who are engaged in exercise. “Consider being certified by the Certification Board for Diabetes Care and Education as a Certified Diabetes Care and Education Specialist (CDCES),” See says. “The more qualifications and credentials you have, the more marketable you are when you want to advance in your career.”

Collaborate, Educate, and Empower Patients

CR/PR professionals’ focus is on a patient’s recovery from a cardiac or pulmonary event, but many of the therapies given to patients for diabetes or COPD can cause complications while the patients are exercising. “There's an opportunity for CR/PR staff to engage with other disciplines,” explains See. “CR/PR professionals can gain confidence through education and training that enables them to thoughtfully address the concerns of their patients with diabetes and help those patients become confident in their own care management.”

CR/PR professionals can take the initiative to find onsite or offsite resources to help patients manage their diabetes through lifestyle changes or speak with their health care team about changes in treatment. According to See, this may lead to the development of a diabetes care management education program for CR/PR patients. In others, it may just be a closer collaboration with patients’ health care teams or identifying already available online resources.