In Brief

Physical activity and the prescription is an integral component of the self-management training (DSMT) plan for any patient with diabetes or anyone at risk for developing type 2 diabetes. Diabetes educators from a variety of health care professions are responsible for the successful inclusion of this component into lifestyle behaviors. Current recommendations describe the multidisciplinary team approach as the preferred delivery system for DSMT.

Diabetes Educators and the Exercise Prescription

The treatment and care of diabetes is Patient Education Programs were based on teaching the skills and infor- first developed by the National mation needed to best manage the dis- Diabetes Advisory Board and pub- Catherine A. Mullooly, MS, RCEP, ease on a day-to-day basis. In this lished in Diabetes Care in 1984. CDE, and Karen L. Kemmis, PT, MS, modern era of medicine, the body of • The National Certification Board of CDE knowledge surrounding the care and Diabetes Educators (NCBDE) prevention of diabetes expands almost offered the first Certified Diabetes hourly. This rapid and expanded Educator (CDE) exam in 1986. understanding has made it necessary • The ADA recognized the first pro- for many different health care disci- grams to meet the National Standards plines to become involved in the dia- for Excellence in diabetes education betes self-management training in 1987. (DSMT) process. As a result, the field • Congress passed Medicare benefits of diabetes education has become a for DSMT in 1997. subspecialty of many health care pro- fessionals. Although progress has been made Over the past few decades, this in many areas of diabetes education, subspecialty has gained momentum as the training, tools, and financial more and more health care profes- resources to implement and maintain sionals have been drawn to the field. physical activity for DSMT and dia- And along the way, these multidisci- betes prevention has not kept pace. plinary professionals have worked This is in contrast to the medical evi- together on task forces, committees, dence supporting the inclusion of exer- and boards to improve the delivery of cise as part of diabetes management in diabetes education. Progress has early Roman and Greek times1 and required tireless effort and a unified again with the discovery of insulin.2 vision. Following is a list highlighting While modern medicine does recognize just a few of the defining moments the role exercise has in diabetes care, it that have resulted from these collabo- is rare to find a successful and effective rative efforts: practitioner. In his writings, Elliott P. • The American Association of Joslin, MD, often highlighted the Diabetes Educators (AADE) was importance of exercise as part of the established in 1974. diabetes management plan. “To many • The American Diabetes Association persons exercise seems a luxury, but a (ADA) presented its first “Outstanding diabetic is fortunate in that he must Educator in Diabetes” Award in 1977. always consider exercise a necessity.”3 • The National Standards for Diabetes Joslin would frequently visit the local 108 Diabetes Spectrum Volume 18, Number 2, 2005 dog shelter in order to “gift” his more goals, exercise/physical activity histo- hypoglycemia. The history of activity- Moving Ahead With Physical Activity / From Research to Practice sedentary patients with a reason to ry, diabetes history including control related hypoglycemia should be inves- walk twice a day. and complications, medical history, tigated to allow recommendations for So, although the importance of orthopedic problems, cardiovascular prevention and treatment with exer- physical activity in the prevention and status, and motivation/psychosocial cise. Hypoglycemia is a common acute treatment of diabetes is well known issues. Physical activity such as house- complication from physical activity in among today’s clinicians,4 the skills, hold chores, yard work, recreational those with diabetes, initially described experience, and knowledge required interests, and activity at work should by Lawrence in 1926.2 All people for the implementation of the exercise be included in the assessment and treated with insulin and those on oral prescription are often lacking. As activity prescription. The assessment medications that increase insulin pro- already stated, diabetes educators is generally carried out individually duction are at risk for hypoglycemia. come from a variety of health care with a diabetes educator but may be Research has shown that intensive backgrounds. Among the health care done in a group format before DSMT. control of blood glucose increases the professionals currently eligible by The exercise prescription should be risk of hypoglycemia with exercise.7 NCBDE criteria to pursue the certified based on the patient’s personal goals. The patient should be asked about diabetes educator certification are reg- Likely goals include improved frequency of hypoglycemia, its rela- istered nurses, dietitians, occupational glycemic control, reduced cardiovas- tionship to exercise/physical activity, therapists, optometrists, pharmacists, cular risk, weight loss, and increased past adjustments to limit hypo- physical therapists, physicians, physi- strength or endurance. Some may glycemia, and results of these adjust- cian’s assistants, podiatrists, social want to exercise for general fitness, ments. The person’s goals should be workers, clinical psychologists, exer- whereas others have competitive ath- assessed to determine adjustments. If cise physiologists, and health educa- letic goals. Diabetes history should weight control or weight loss is a tors.5 Regardless of academic prepara- include type of diabetes, duration of goal, attempts should be made to plan tion or professional training, any of diabetes, presence of complications of for exercise and to decrease the rapid- these professionals can be responsible diabetes, treatment for glucose con- or fast-acting insulin that is working for developing and implementing the trol, frequency of self-monitoring of at the time of exercise. If the person is exercise prescription as part of the blood glucose, frequency of hypo- not concerned about the consumption DSMT plan. It is important to note glycemia, including severity and rela- of extra calories to allow for exercise that only physical therapists and exer- tionship to activity, and current dia- (growing children and adolescents or cise physiologists have studied acade- betes control (hemoglobin A1c). The slender adults) or if the activity is not mic curriculums and performed clini- presence of neuropathy, foot deformi- planned, additional carbohydrate can cal internships developed specifically ties, current or past open wounds, be consumed. to meet the health challenges and fit- retinopathy, macular edema, glauco- Blood glucose monitoring may ness needs of patients encountered in ma, nephropathy, and cardiovascular need to be increased before, during, a medical setting. disease (CVD; coronary artery dis- and after activity to determine the This article will provide guidance ease, congestive heart failure, periph- need for insulin adjustments or snack- for diabetes educators regardless of eral vascular disease, or cerebrovascu- ing. People with diabetes should be health care background by defining lar accident) should be addressed. questioned about the availability of the assessment process and the infor- People with type 2 diabetes may fast-acting glucose during and after mation required to develop the exer- have had elevated blood glucose levels exercise. Commonly used treatments cise prescription. It will also examine for some time before the diagnosis of include glucose tablets, glucose gel, the contributions of clinical exercise diabetes. Complications of diabetes juice, sports drinks, and sugar. A professionals to the diabetes team, may be present at the time of diagno- review of hypoglycemia treatment specifically within the scope of prac- sis. People with type 2 diabetes may should be performed frequently but tice for reimbursement potential. And need a more extensive pre-exercise specifically when activity level will be finally, professional resources will be evaluation from the time of diagnosis changing, after a hypoglycemic highlighted and recommended for all compared to those newly diagnosed episode, and with changes in the med- diabetes educators to investigate. with type 1 diabetes. Examples ication regimen. Patients should be include more extensive cardiac and encouraged to contact the diabetes Assessment for an Exercise ophthalmological examinations, educator and/or physician if severe or Prescription which will be described later. frequent hypoglycemia occurs, to Before initiation of an exercise pro- Information about the duration of allow for medication adjustments. gram, people with diabetes should diabetes guides the pre-exercise evalu- People who increase their activity and undergo a medical assessment. The ation for this same reason. A person experience hypoglycemia may report ADA recommends a medical evalua- with type 1 diabetes of short duration increased weight in spite of increased tion to screen for the presence of may not need extensive testing regard- activity.7 It is important to ask micro- and macrovascular complica- ing complications, which may be rec- patients directly about hypoglycemia tions that could be worsened by phys- ommended for those with type 1 dia- because they may forget to report ical activity. Glycemic control should betes of longer duration. episodes, self-treat repeatedly, and be evaluated as well.6 Once this evalu- Treatment for glycemic control may subsequently experience weight gain. ation has been done, an exercise range from meal planning and exercise Because many people exercise at least assessment should be carried out to to oral agents to insulin or some com- in part to lose or control weight, allow prescription of an appropriate bination of these. This is important hypoglycemia is a troublesome and exercise program for the individual. information with regard to exercise potentially dangerous result that can This will be based on the person’s when considering the likelihood of be minimized with education. 109 Diabetes Spectrum Volume 18, Number 2, 2005 The ADA recommends guidelines with overt nephropathy will often When a patient with diabetes is to avoid exercise-induced hypo- have diminished capacity for activity, being counseled to begin a fitness pro- glycemia in insulin-treated patients. causing a self-limitation on strenuous gram that exceeds the demands of Blood glucose testing may be neces- exercise.8 everyday living (more intense than sary before, during, and after exercise. Medical and orthopedic history brisk walking), a graded exercise test Extra carbohydrate may need to be will be valuable when creating a safe should be seriously considered in pre- consumed before unplanned exercise, exercise prescription. Common med- viously sedentary individuals. This and insulin may need to be decreased ical problems that would be impor- would correlate to meeting any of the after the activity. Insulin doses may be tant include hypertension, orthostatic following criteria: decreased before and after exercise. hypotension, syncope, history of falls, • Age > 40 years with or without The amount will depend on the inten- dyspnea on exertion, dyslipidemia, CVD risk factors other than dia- sity of exercise, duration of exercise, and current medications and their side betes and past experience of the patient. effects. People with an increased risk • Age > 30 years and Easily absorbable carbohydrate may of falls should be guided to activities • Type 1 or type 2 diabetes of need to be consumed during exercise, that minimize this risk. Sitting activi- > 10 years’ duration and additional carbohydrate may be ties are encouraged (stationary bike), • Hypertension necessary after activity.8 whereas those with quick changes • Cigarette smoking Presence of complications will dic- from sitting to standing and those • Dyslipidemia tate the exercise assessment and pre- likely to increase the risk of falls • Proliferative or preproliferative scription. Foot conditions that limit should be discouraged. Dyspnea on retinopathy weight-bearing exercise include an exertion and dyslipidemia are often • Nephropathy, including micral- insensate foot, foot deformities related to increased risk of cardiovas- buminuria (cocked-up toes and Charcot foot), cular problems, which will be dis- • Any of the following, regardless of foot ulcer, and previous foot ulcer.8 cussed later. age The exercise assessment and prescrip- Orthopedic problems commonly • Known or suspected coronary tion offer an opportunity for the edu- interfere with physical activity. An artery disease, cerebrovascular cator to review foot care guidelines, evaluation should include current and disease, and/or peripheral vascu- including visual inspection and proper past painful conditions. Types of lar disease footwear. activities that tend to increase and • Autonomic neuropathy The presence of retinopathy should decrease pain should be reviewed with • Advanced nephropathy with be evaluated to allow safe activity each patient. For example, some peo- renal failure guidelines based on level of retinopa- ple with low back pain may report an thy. All patients with type 2 diabetes increase in pain with walking and a Problems with motivation and psy- and those with type 1 diabetes who decrease in pain with sitting, making chosocial issues often interfere with are over the age of 10 years and have recumbent activities, such as riding a adherence to an exercise regimen and had diabetes of > 3–5 years’ duration stationary bike, an exercise option. the level of physical activity. The should have a dilated eye exam before Others with back pain get relief with assessment can address these issues by starting an exercise program.8 People walking, allowing this as a possible considering social support (emotional without diabetic retinopathy or who exercise. support as well as exercise partners), only have mild nonproliferative dia- Some people may need an interven- interests, past successes and challenges betic retinopathy (NPDR) do not tion before starting an exercise pro- with exercise, and time of day most have activity limitations. Those with gram, such as an orthopedic evalua- likely to allow consistency of exercise. moderate, severe, and very severe tion or to decrease Interest and convenience of exercise NPDR and those with proliferative pain and allow for a subsequent options should be addressed. People diabetic retinopathy should be edu- increase in exercise. Common ortho- with diabetes should provide exercise cated on the limitations for activity, pedic problems that limit exercise and preferences, though educators may including exercise and routine activi- activity include neck and low back need to offer options that may not be ties.8 Macular edema and glaucoma pain, degenerative joint disease in the evident to patients. There may be psy- should be evaluated by an ophthal- hip, plantar fasciitis, shoulder pain, chosocial benefits from exercise. mologist or optometrist with activity and a variety of conditions that cause However, depression, stress, and anxi- guidelines determined by the results knee pain. ety may need to be controlled to allow of the examination. Because CVD is the major cause of the initiation of an exercise routine. Nephropathy should be taken into mortality for people with diabetes, a The exercise prescription should be account when prescribing intensity of careful evaluation should be per- realistic to allow early successes. This exercise. Light to moderate exercise is formed before initiating an exercise includes choosing an appropriate generally considered safe and benefi- program. First, the existence of any mode, duration, frequency, and inten- cial for those with incipient cardiac risk factors should be deter- sity of exercise. Once the routine is nephropathy or microalbuminuria mined and emphasis should be placed established, increases can be made to (30–299 mg/day). For those with on their treatment in the attempt to reach long-term exercise goals. overt neph-ropathy or clinical albu- prevent or slow CVD. These risk fac- minuria (> 300 mg/day), strenuous tors include dyslipidemia, hyperten- Exercise Prescription Within the exercise (> 70% maximum heart rate sion, smoking, a positive family histo- Diabetes Team or > 60% of the maximal volume of ry of premature coronary disease, and Physicians are only able to provide oxygen. that can be consumed the presence of micro- or macroalbu- sporadic exercise counseling during 6 9 [VO2max]) should be avoided. People minuria. clinic visits. One study concluded 110 Diabetes Spectrum Volume 18, Number 2, 2005 that “although adults with [diabetes] financial resources to support exercise Sports Medicine (ACSM) as someone Moving Ahead With Physical Activity / From Research to Practice have a high prevalence of modifiable facilities or to hire clinical exercise who “works in the application of CVD risk factors, counseling by professionals. However, in contrast to exercise and physical activity for those physicians about lifestyle modification clinical staffs, the research literature clinical and pathological situations is less than optimal. There is a need to frequently reveals the inclusion of where it has been shown to provide improve patient counseling for clinical exercise professionals as part therapeutic or functional benefit. lifestyle modification by primary care of the team performing diabetes edu- Patients for whom services are appro- physicians.”10 While still controver- cation investigations,15,16 lifestyle priate may include, but not be limited sial, there is some indication in the lit- modification studies,17,18 and diabetes to, those with cardiovascular, pul- erature that diabetes “sub-specialist prevention efforts.19,20 The next sec- monary, metabolic, immunological, care clearly improves long-term, clini- tions will review the scope of practice inflammatory, orthopedic, and neuro- cally important outcomes in patients and the reimbursement potential of muscular diseases and conditions. with diabetes. Our challenge as a soci- two types of clinical exercise profes- This list will be modified as indica- ety is to provide more endocrinolo- sional: physical therapists and clinical tions and procedures of application gists and other members of the dia- exercise physiologists. are further developed and matured. betes team who are intensively educat- Furthermore, the clinical exercise ed specialists devoted to the care of Physical Therapists physiologist applies exercise principles patients with diabetes.”11 Physical therapists have the knowl- to groups such as geriatric, pediatric, The AADE has identified primary edge and training to develop safe or obstetric populations, and to soci- areas of responsibility for diabetes exercise programs for people with dia- ety as a whole in preventive activities. educators. The Scope of Practice betes.21 Physical therapy is defined as The clinical exercise physiologist per- charges diabetes educators with incor- “the evaluation, treatment, or preven- forms exercise evaluation, exercise porating physical activity into the tion of disability, injury, disease, or prescription, exercise supervision, lifestyle of people with diabetes.12 In other condition of health using physi- exercise education, and exercise out- 2003, the AADE published data that cal, chemical, and mechanical means come evaluation. The practice of the identified seven behaviors common including . . . therapeutic exercise with clinical exercise physiologist should be among patients who are able to or without assistive devices, and the restricted to clients who are referred achieve better health outcomes with performance and interpretation of by and are under the continued care diabetes. “Being active” is listed as tests and measurements to assess of a licensed physician.”24 one of the AADE’s seven self-care pathophysiological, pathomechanical, The written exam to become a reg- behaviors, emphasizing that even and developmental deficits of human istered clinical exercise physiologist is small changes in the physical activity systems to determine treatment, and one of the clinical track certifications levels are considered beneficial.13 The assist in diagnosis and prognosis.”22 offered by the ACSM. This exam is remaining behaviors are eating The practice of physical therapy restricted to candidates who complete healthy, monitoring, taking medica- varies from state to state; however, a graduate degree in exercise science, tions, problem solving, using coping the key points of this definition are , or physiology skills, and reducing risk. fairly consistent. Given this, physical from a regionally accredited college or In all ADA-recognized diabetes therapists are an excellent source for university and who accumulate the education programs, exercise is a for- those with diabetes for evaluation and required number of relevant experi- mal part of the curriculum.14 It is also prescription of exercise. People with ence hours.24 required that education teams consist cardiovascular and/or musculoskeletal At this time, clinical exercise physi- of a minimum of a nurse educator and problems would especially benefit ologists cannot bill directly for their a dietitian. Other potential members from consultation from a physical time spent supervising exercise ser- of the team include an exercise spe- therapist. Some states allow patients vices and sessions. This will most like- cialist, a pharmacist, a podiatrist, a to access the services of a physical ly be reexamined as changes occur psychologist/social worker, and a therapist without a referral, whereas within the profession that lead to physician. Regardless of who makes others require a referral from a physi- licensing. Until then, these exercise up the education team, it is the cian or other health professional. professionals provide patient care col- responsibility of team members to Physical therapists should consult the laboratively with other health profes- assess the exercise needs of patients, practice act in their state for details sionals who are able to process the to teach the appropriate educational regarding referral and practice guide- insurance information within well- content, and to oversee behavior lines. Insurance reimbursement is gen- ness, cardiopulmonary rehabilitation, change as it progresses. Most of the erally available for interventions relat- and physical therapy programs. In time, the performance of the exercise ed to the management of diabetes. regard to diabetes, there is no accept- prescription is left to the patients to However, exercise programs pre- ed coding that can be reimbursed for try on their own. While diabetes edu- scribed and monitored for the preven- exercise sessions. However, while cators would never let patients leave tion of diabetes may not be covered.23 exercise sessions cannot be billed for a their office without being able to diabetes population, there is reim- demonstrate that they can use a blood Clinical Exercise Physiologists bursement for DSMT delivered by glucose meter or safely inject insulin, Exercise physiologists can be found diabetes educators. patients rarely have the opportunity working in many different settings. to be supervised when learning how The main areas have been academic, Diabetes Educators to perform the exercise prescription. fitness, research, and clinical. The role AADE defines diabetes educator as a There are many reasons why this of clinical exercise physiologists is “healthcare professional who has occurs; most are because of a lack of defined by the American College of mastered the core of knowledge and 111 Diabetes Spectrum Volume 18, Number 2, 2005 skills in the biological and social sci- Disabilities. Champaign, Ill., and upholding the core competen- ences, communication, counseling, Human Kinetics, 2003 cies required by diabetes educators and education, and who has experi- ACSM’s Guidelines for Exercise in determining the appropriate and ence in the care of people with dia- Testing and Prescription. 6th safe exercise prescription. AADE betes. The role of the diabetes educa- ed. Franklin BA, Ed. Baltimore, members can learn more about tor can be assumed by various health- Md., Lippincott, Williams & this SPG in the Members section care professionals, including, but not Williams, 1999 of the organization’s website limited to, registered nurses, registered • American Diabetes Association (www.diabeteseducator.org). dietitians, pharmacists, physicians, Handbook of Exercise in • The Diabetes and Exercise Sports mental health professionals, podia- Diabetes. Ruderman N, Devlin Association (DESA) exists to trists, and exercise physiologists. A JT, Schneider SH, Kriska A, enhance the quality of life of people goal for all diabetes educators should Eds. Alexandria, Va., American with diabetes through exercise and be to meet the academic, professional, Diabetes Association, 2002 physical fitness. The membership and experiential requirements to Sigal RJ, Kenny GP, Wasserman base is made up of people with dia- become a certified diabetes educator DH, Castaneda-Sceppa C: betes and health professionals in (CDE).”12 Physical activity/exercise and type diabetes who have an interest in However, the CDE credential does 2 diabetes (Technical Review). physical activity. Three levels of not allow health care professionals to Diabetes Care 27:2518–2539, membership are available: General, practice outside of their professional 2004 Youth (for individuals under the scope of practice. While this may • American Association of Diabetes age of 18 years), and Professional. sound contradictory, it is best Educators Complete membership information summed up by the AADE’s statement: Physical activity/exercise. In A is available online (www.diabetes- “The role of the diabetes educator is Core Curriculum for Diabetes exercise.org). multidimensional, with boundaries for Educators: Diabetes Management accountability that interface with Therapies. 5th ed. Franz M, Ed. Summary other members of the healthcare team. Chicago, American Association of The exercise prescription for patients This role involves the education of Diabetes Educators, 2003 with diabetes can involve a multitude people with diabetes, their families, of tasks, volumes of evidence-based and appropriate support systems, as In addition to written materials, information, and interdisciplinary well as other healthcare professionals there are organizations that offer involvement of the health care profes- who do not specialize in diabetes opportunities for diabetes educators sionals concerned with their care. management, such as policy makers to contribute, learn, and explore new That said, the outcome of all of this and the public. A multidisciplinary resources and treatment strategies for time and knowledge may result in no team approach is the preferred deliv- diabetes and exercise. Again, here are more than a simple walking program ery system for diabetes education. a few such organizations with which for patients to perform. Yet patients This specialty practice can occur suc- the authors are familiar and which are deserve nothing less than this collec- cessfully in a wide variety of settings well respected in the diabetes commu- tive effort. The potential risks of and formats.”12 nity: beginning an exercise program often Reimbursement for diabetes educa- • Professional section members of have to be balanced with the presence tors providing DSMT is available for the ADA can opt to join its of other diseases, diabetes complica- programs that meet insurance indus- Council on Exercise. This council tions, and medication regimens. With try standards. While these are subject provides a forum for members to the assistance of trained and informed to change, currently all ADA-recog- discuss the benefits, risks, and diabetes educators, patients can be nized education programs can submit practical problems related to exer- assured, motivated, and confident that for insurance coverage. The education cise for patients with diabetes and they are spending their time effectively services required to assess, design, related disorders. It also offers and in harmony with their overall dia- implement, and measure the exercise mechanisms for disseminating new betes goals. prescription are all well within DSMT information about the effects of So where can one find a clinical standards and guidelines. exercise to both the medical and exercise professional who wants to be general communities and assists in part of an interdisciplinary team of Professional Resources establishing national standards for diabetes educators? To be honest, Evidence-based research is the corner- the development of safe and effec- they are few and far between. There stone of good medical care. Fortun- tive exercise programs. ADA mem- have never been more than a few ately, there are some well-written, bership information is available dozen CDEs who have listed as their peer-reviewed resources that interpret online (www.diabetes.org). primary job either physical therapist the research to provide the latest • Active members of the AADE can or exercise physiologist. Within the health information and fitness guide- choose to join its Physical Activity greater diabetes community, the chal- lines for patients with diabetes. Specialty Practice Group (SPG). lenge is to evaluate the missing links Following are a few of the resources This is a group of multidisciplinary in existing programs and determine if that are known to the authors and are diabetes educators attempting to there is a role for such a team mem- well respected in the exercise or dia- increase awareness of and provide ber. Programs that now exist without betes fields: guidance for physical activity as a an exercise specialist can look to their • ACSM means of diabetes prevention and institution’s cardiopulmonary rehabil- Exercise Management for Per- treatment. Its members are com- itation program or physical therapy sons with Chronic Diseases and mitted to identifying, perpetuating, department to recruit a clinical exer- 112 Diabetes Spectrum Volume 18, Number 2, 2005 18 cise professional that could provide Alexandria, Va., American Diabetes Association, Arthur H, Smith KM, Kodis J, McKelvie R: A Moving Ahead With Physical Activity / From Research to Practice DSMT expertise. With mentoring 2002 controlled trial of hospital versus home-based exercise in cardiac patients. Med Sci Sports Exerc from other diabetes educators, this 9Wee CC, McCarthy EP, Davis RB, Phillips RS: 34:1544–1550, 2002 professional could accumulate the Physician counseling about exercise. JAMA practice experience hours required to 282:1583–1588, 1999 19The DPP Research Group: Reduction in the move toward the CDE examination, 10Egede LE, Zheng D: Modifiable cardiovascular incidence of type 2 diabetes with lifestyle inter- provide an added value to the delivery risk factors in adults with diabetes: prevalence vention or metformin. N Engl J Med 346:393–403, 2002 of the DSMT program, and offer a and missed opportunities for physician counsel- competitive edge by providing a ing. Arch Intern Med 162:427–433, 2002 20Lindstrom J, Louheranta A, Mannelin M, unique skill set to the team. 11Cobin RH: Subspecialist care improves diabetes Rastas M, Salminen V, Eriksson J, Uusitupa M, outcomes. Diabetes Care 25:1654–1656, 2002 Tuomilehto J: The Finnish Diabetes Prevention Study. Diabetes Care 26:3230–3236, 2003 References 12American Association of Diabetes Educators: The scope of practice for diabetes educators and 21American Physical Therapy Association: 1Sushruta SCS: Vaidya Jadavaji Trikamji the standards of practice for diabetes educators, Available online at http://www.apta.org/Career_ Acharia. Bombay, India, Sagar, 1938 1999. Available online at http://www.diabetes center/career_management/niche_practices. educator.org. Accessed 6 November 2004 Accessed 6 November 2004 2Lawrence RH: The effects of exercise on insulin action in diabetes. BMJ 1:648–652, 1926 13Mulcahy K, Maryniuk M, Peeples M, Peyrot 22Available online at http://assembly.state.ny.us/ M, Tomky D, Weaver T, Yarborough P: 3Joslin EP: A Diabetic Manual for Doctor and leg. Accessed 6 November 2004 Diabetes self-management education core out- Patient. 9th ed. Philadelphia, Pa., Lea & Febiger, 23 comes. Diabetes Educ 29:768–803, 2003 Available online at http://www.apta.org/ 1953 Career_center/career_management/niche_ 14 4Sigal RJ, Kenny GP, Wasserman DH, American Diabetes Association: National stan- practices. Accessed 6 November 2004 dards for diabetes self-management education. Castaneda-Sceppa C: Physical activity/exercise 24 Diabetes Care 28 (Suppl. 1):S72–S79, 2005 American College of Sports Medicine: and type 2 diabetes (Technical Review). Diabetes Available online at http://www.acsm.org. Care 27:2518– 2539, 2004 15Raji A, Gomes H, Beard JO, MacDonald P, Accessed 6 November 2004 5National Certification Board of Diabetes Conlin PR: A randomized trial comparing inten- Educators eligibility criteria. Available online at sive and passive education in patients with dia- http://www.ncbde.org. Accessed 8 November betes mellitus. Arch Intern Med 162:1301–1304, Catherine A. Mullooly, MS, RCEP, 2002 2004 CDE, is a clinical exercise physiolo- 16 6American Diabetes Association: Standards of Elley CR, Kerse N, Arroll B, Robinson E: gist, a diabetes educator, and team medical care in diabetes (Position Statement). Effectiveness of counseling patients on physical leader of the Exercise Physiology Diabetes Care 27 (Suppl. 1):S4–S36, 2005 activity in general practice: cluster randomized controlled trial. BMJ 326:793–798, 2003 Department at the Joslin Clinic in 7 Boston, Mass. Karen L. Kemmis, PT, American Diabetes Association: Implications of 17 the Diabetes Control and Complications Trial Rutledge JC, Hyson DA, Garduno D, Cort DA, MS, CDE, is a physical therapist, (Position Statement). Diabetes Care 26 (Suppl. Paumer L, Kappagoda CT: Lifestyle modification exercise physiologist, and diabetes 1):S25–S27, 2003 program in management of patients with coro- nary artery disease: the clinical experience in a educator at the Joslin Diabetes Center 8Ruderman N, Devlin JT, Schneider SH, Kriska tertiary care hospital. J Cardiopulm Rehabil affiliate at SUNY Upstate Medical A (Eds.): Handbook of Exercise in Diabetes. 19:226–234, 1999 University in Syracuse, N.Y.

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