Exercising Safely at Home During The COVID-19 Pandemic

Benefits of exercise for people with diabetes during COVID-19

Regular exercise can benefit physical and mental health for people with diabetes prior to the pandemic^1-4 . This has also been an important consideration during the COVID-19 pandemic^5-7. For individuals with diabetes specifically, exercise has been found to improve cardiovascular fitness, decrease fat mass, increase muscle mass (thereby improving strength), improve insulin sensitivity and reduce diabetes distress^{3, 4, 8}. The current recommendations for individuals with diabetes to achieve these benefits, are to participate in a combination of aerobic exercise (on most or all days of the week) and resistance exercise (2-3 x weekly)⁸ . 

The impact of the COVID-19 pandemic and associated restrictions/lockdowns has been well documented. A national survey of 13829 Australian adults after the first month of COVID-19 restrictions found that mental health problems, including depression and generalised anxiety, were at least twice as prevalent as in non-pandemic circumstances⁹ . Individuals living alone, living in poorly resourced areas, those caring for dependant family members, those living with chronic conditions and pre-existing mental health conditions are at greater risk of experiencing higher levels of anxiety during COVID-19^{9, 10} . It is therefore important that individuals in need have access to mental health services (either face to face or via telehealth) during this period¹⁰ . Exercise has also shown to improve mental health. Many studies have shown that all types of exercise and physical activity can release endorphins^{1, 8, 10-13} and exercise may act as an antidepressant¹ . During COVID-19, telehealth exercise 1:1 with a practitioner or in a group setting provided a platform for social interaction with others. Social support has been shown to help individuals manage stress better, improve mental health^{14, 15} and benefit a range of physical health outcomes such as cardiovascular health¹² .

Tips for exercising at home 

There are many ways to exercise at home, but before any of that, it is important to consider a few factors. Are there safety considerations at home i.e. safe space, temperature, environment, appropriate footwear and clothing for the client to exercise in? Is their doctor aware of the client commencing exercise? Do they need medical clearance prior to commencing? If there are any concerns, it is recommended that the client speak to their AEP to ensure their home environment is safe and is appropriate for exercise¹⁶ . If a client is unable to have immediate access to an AEP, it is recommended for them to speak with their GP prior to commencing exercise.

An AEP will perform a pre-screening assessment prior to prescribing an exercise program for an individual with diabetes. The assessment includes reviewing their medical history and may include some subjective questionnaires and physical measures to determine if there are any safety concerns and the type of exercise that is right for them16. During this time, the AEP will examine:

• An individual’s motivation to exercise i.e. do they want to keep up with their children or fit into their favourite dress? 
• A client’s barriers towards exercise i.e. time constraints, dislike to exercise, religion, cost etc. 
• An individual’s likes and dislikes?
• What type of exercise would suit the individual’s lifestyle I.e. would this include family or friends? Or will it be a 1:1 session with a health professional or group setting? 

Once an assessment has been completed and it is determined that the client is safe to begin exercising, an individualised exercise program can be developed. This could be going for a walk or swim or a home-based program using their body weight or some basic exercise equipment such as dumbbells and resistance bands. It is important to remember that someone does not need equipment to exercise effectively. There are many ways for someone to exercise using household items or their body weight. However, some clients feel increased motivation with new equipment or a new outfit¹⁷ and this may assist with longer term involvement in the exercise program⁴ . Many large retailers have affordable activewear or small equipment including dumbbells or exercise bands. There are options to have these exercises performed individually, in a small group face to face or even virtually via programs such as Zoom. Other online pre-recorded videos may be appropriate for low-risk, highly motivated clients with good body awareness. However, they may not be appropriate for all individuals, so if unsure the client is encouraged to contact their AEP to ensure their safety. Remember, everyone is different and there is no ‘one size fits all approach’ in regards to a physical activity regime.

It is recommended that people with diabetes review their current physical activity status with their AEP at least once per year as a part of their annual cycle of care^{14, 16} . Some individuals may find greater benefit in having more frequent contact with their AEP with monthly reviews or even weekly 1:1 or group sessions, particularly if they. require motivational support and/or present with barriers to exercise.

How AEPs supported individual’s during the COVID-19 pandemic

COVID-19 changed the way healthcare has been delivered in Australia and across the world. 

BallyCara is a not-for-profit organisation providing HomeCare, Residential and Wellness services around south east Queensland, northern New South Wales and north Melbourne.  Like many, the organisation had challenges during the COVID-19 pandemic including trying to promote healthy lifestyles following government advice while in lockdown at home. The health professionals (including the AEPs in the wellness team) in all regions were creative in their approach to deliver successful exercise interventions to their community members.

The BallyCara executive and management teams ensured policies, procedures and planning were regularly monitored and reviewed following the guidelines through the Department of Health¹⁸ . Having a supportive workplace with regular updates and good communication made following these guidelines as a staff member easy. During visits, staff were required to ask pre-screening questions and wear personal protective equipment (PPE) such as a mask, gloves and gown when unable to socially distance with clients. During these sessions, effective communication and good demonstration of exercise was required for best client outcomes. 

For clients who were safe to independently exercise at home and had access to the internet and a smart device, telehealth sessions were offered. Most clients were quite open and excited about the new technology and appreciated being able to choose from a range of activities. Options included pre-recorded videos (via internet, DVD or USB access), telehealth 1:1 or group sessions, individualised, self-managed home exercise programs and assistance in purchasing small equipment (such as dumbbells and exercise bands). Clients who had higher levels of self-motivation preferred the home video and exercise program options, whereas others preferred to exercise under the direct supervision and with the support of an AEP in person with additional PPE. However, some clients were faced with barriers such as internet access, use of smart devices and technological literacy. Telehealth services could be accessed 1:1 with their AEP or in a group exercise setting which also provided social interaction with other community members. Increased social interaction during the COVID-19 pandemic combated some negative symptoms of isolation and decreased symptoms of anxiety and depression^9-11 .  For those who preferred to continue with 1:1 face to face sessions, these were offered with increased PPE and social distancing.

Tips for CDEs

CDEs play an important role in assisting individuals with diabetes to make positive changes to their lifestyle habits to improve their diabetes management. Much research has shown positive impact on diabetes management of moving more (even without a specific exercise program) and sitting less^{3, 8, 17 .} If a client has many chronic conditions or sub-optimally managed diabetes, it is recommended that they see their GP and/or AEP prior to commencing a new exercise regime. CDEs can support clients with physical activity by:

• Providing tips for increasing incidental exercise (including parking further away at the shops, taking the stairs instead of the lift, walking the long way to the register when buying something)
• Encouraging them to sit less (for example, setting a silent alarm on the computer to stand up every 30-45mins, using a smart watch/alarm on the phone to remind office workers to stand up)
• Providing clients with resources from ‘Exercise Right Australia’ https://exerciseright.com.au/ or ‘Exercise is Medicine Australia’ http://exerciseismedicine.com.au/ 
• Providing clients with information to the ‘Beat It’ program. This program is funded through the NDSS to provide clients with diabetes 8 weeks of physical activity and lifestyle support (some providers run sessions face to face or virtually by an AEP) https://diabetesnsw.com.au/about-us/blog/beat-it-exercse-program/
• Providing clients who are inactive and over 65 years old information to the ‘Exercise Right for Active Aging’ program. This program is funded through the Australian Government (with a small contribution) to provide clients with 12 weeks of physical activity (some providers run sessions face to face or virtually by an AEP)  https://exerciseright.com.au/betterageing/ 
• Referring them to a local AEP or the ‘Find an AEP’ section on the ESSA website https://www.essa.org.au/find-aep