BOSTON – Obese children with type 2 diabetes and those with hypertension can safely engage in moderate to strenuous physical activity, with a few modifications and some common sense.
Heat-related illness and glucose regulation are the top issues for pediatricians who prescribe exercise for such patients – and these small athletes need supervision by an adult who can monitor them. But almost always, exercise is more beneficial than it is risky, Dr. Claire LeBlanc said at the annual meeting of the American Academy of Pediatrics.
"As long as their conditions are well controlled [and there is no organ damage], we want them to do lifestyle modification and get 60 minutes per day of moderate to vigorous physical activity," said Dr. LeBlanc, a pediatric rheumatologist at the University of Alberta, Edmonton.
But, she added, it’s important to loop in other physicians on the child’s care team. "Include your specialists, like cardiologists, especially if there are issues," and a child is becoming symptomatic.
A few basics are in order for any hypertensive child who begins to exercise, she said. "Obese children have a higher risk of poor heat tolerance and heat illness, so it’s important to consider acclimatization and conditioning." Use caution if children are exercising in a hot or humid environment, and make sure they are well hydrated. Although sodium is a concern with hypertension, these children might actually need a little extra salt if they are exercising strenuously.
Activity recommendations vary with the disease stage:
• Prehypertension. Any competitive sport is okay; the goal is 60 minutes per day of moderate to vigorous exercise. Encourage parents to keep children on a well-balanced diet and monitor blood pressure about twice a year.
• Stage 1 hypertension with no organ damage. Again, there’s no limit on eligibility for competitive sports. But if the child becomes symptomatic during exercise or if the blood pressure is persistently elevated, it’s time to check in with a cardiologist. Dietary modification is also a must.
• Stage 2 hypertension with no organ damage. Unless the blood pressure is stabilized by lifestyle modifications and/or drug therapy, these children shouldn’t engage in high-static sports (A high-static exercise is when there are high levels of isometric muscle contraction, when the muscle fires but there is no movement at a joint. Examples include gymnastics, yoga, rock climbing, and downhill skiing). Sports like boxing, weight lifting, and wrestling can cause acute increases in systolic, diastolic, and mean arterial pressures. A specialist should check out the new athlete after 1 week of exercise if all is going well, but be called immediately if the child becomes symptomatic.
• Hypertension plus cardiovascular disease. Competitive sports might not be out of the question based on the type of heart disease and its severity, but consult with a specialist before advising.
Children with type 2 diabetes can reap huge benefits from exercise, but there are still a few things to keep in mind before setting them loose on the playground or hockey field.
"These children can develop hypoglycemia during exercise, especially if they’re on insulin or oral agents," Dr. LeBlanc said. "To avoid hypoglycemia, be careful about the timing of insulin and exercise," avoiding exercise at the peak of insulin action.
Glucose should be tested before, during, and after exercise. Carbohydrate intake might need adjustment, and emergency glucose needs to be available to treat any emergent hypoglycemia. Adequate hydration is a must.
Hyperglycemia also can be a problem. "There should be no vigorous exercise if the blood glucose is above 250 mg/dL and there is also ketonuria or ketonemia," she said.
As with any diabetes patient, foot care is king. "Make sure there are no blisters or cuts that can become infected and cause problems," Dr. LeBlanc advised. This might mean putting limits on weight-bearing exercise, if the child has early signs of peripheral neuropathy.
"A medic alert bracelet [identifying the child as having diabetes] is always a good thing," she said. "But if the diabetes is under control and there are no serious complications, there are really no restrictions on physical activity."
Dr. LeBlanc said she had no relevant financial disclosures.