You are the clinical exercise physiologist for a 55 year old man (DD) recently diagnosed with Type II diabetes. He is 5’ 10” (178 cm) and weighs 220 lb (100 kg); BMI = 31.6 kg/m2 with an HbA1C of 6.6%. He has no diabetes-related complications (e.g., peripheral or autonomic neuropathy), no other co-morbidities, and is taking no medications.

A cardiopulmonary stress test (CPT) on a cycle ergometer reveals a normotensive exercise response and unremarkable EKG with no arrhythmias or ST segment changes. His peak HR is 160 bpm and his VO2max is 28.0 mL/kg/min with a 200 W peak.

DD is trying to improve his glycemic control and lose weight via diet and exercise. For the last four months, he has been walking at a moderate pace for 30 min x 3 d/wk on his own.

You have been working with DD for two weeks and have put him on a low carbohydrate, high fat, ketogenic diet (LCHF) in which he consumes < 20 g carbohydrate (CHO) per day. He has tolerated the diet well and has noticed that his fasting blood glucose in the morning before breakfast is now around 110 mg/dL instead of the 145 mg/dL that was typical prior to beginning the LCHF diet.

He comes to your facility to exercise four days per week at 1300 (1pm), several hours after his mid-morning LCHF meal. For the first two weeks of his LCHF diet, his blood glucose has been in the 105-110 mg/dL range at the beginning of his exercise sessions; the sessions have gone well with no symptoms or hypoglycemic responses. Today on arrival, his blood glucose is 90 mg/dL (5 mM/L) and his blood ketones are 1.5 mM/L.

Question 1: What is your exercise prescription for DD for the next several weeks? Discuss cardiopulmonary exercise (mode, duration, intensity), resistance exercise (RE; mode, duration, intensity), and range of motion (ROM) and balance training. You do not need to write a fully detailed program, but a good outline of one. Explain your thought process (e.g., if you decide to prescribe higher intensity, state what the potential benefits are and why it is an appropriate choice for this patient). I repeat: I want to know your rationale for your recommendations.

Question 2: Given all of the above information (diet, exercise history, blood glucose), does DD need to ingest supplemental CHO prior to today’s moderate intensity continuous cardiopulmonary workout and if so, how much? Again, clearly and thoroughly describe your thought process and rationale for your answer/decision—don’t simply repeat the basic recommendations from the textbook.

Be sure to provide references in your answers.