What Does Success with Diabetes Management Really Mean?

What does it mean to be successful when it comes to managing your diabetes? That seems like a simple question that should have an equally straight-forward answer, but nothing could be farther from the truth when it comes to diabetes.

The focus of successful diabetes management is usually on blood glucose. How low can you get your A1C? What is your “time in range” if you use a continuous glucose monitor? How many lows are you experiencing, and how many highs? While some of these questions are relevant to your short- and long-term health with diabetes, there is a lot more to consider than just how close to optimal your glucose numbers are or aren’t.

For example, consider how diabetes is affecting your daily life. A measure of success for me is keeping my diabetes management to a dull, background noise—something that I’m aware of from time to time but that does not command my full attention most of the day. You likely have to think about your blood glucose when you’re choosing what to eat or remembering to take your medications or picking doses. The rest of the time, you are experiencing success when it’s not interfering much in your life. Of course, we all have bad days when diabetes management takes up more time or more of our focus, but having as few of those days as possible is definitely a measure of success.

Personally, I consider myself successful when I have a good night’s sleep. Anyone with diabetes knows that sleeping well can be a challenge for multiple reasons. Having your glucose go low during the night interferes with good sleep (and, for me, makes it hard to fall back to sleep after I treat it). Having it go too high can make you have to go to the bathroom a lot at night, which also can interfere with sleep. Aging itself has the potential to interfere with good sleep, so it is not just diabetes that you may have to manage. These days when I manage to sleep three to four hours at a time between waking up and have stable blood glucose levels overnight, I consider myself as being successful managing it.

Avoiding health complications associated with diabetes is also a measure of success to many, but not a goal that is entirely within most people’s control. It’s possible to have health issues come up that have nothing to do with diabetes, and even people with the most stringent blood glucose management can develop health problems over time. Unfortunately, the tools and medications that are available to treat diabetes are less than perfect. For instance, if you have to take insulin, there is no way currently to deliver it where it would normally be released in the circulation leading to your liver. So, at best, your metabolism of the insulin you take is altered because you have to inject, pump, or inhale it. While doing the best with the tools you have available is a measure of success, do yourself a favor and stop expecting perfection. It’s really not possible at this point in time due to limitations outside our control.

Enjoying your life as much as possible despite having diabetes is a true measure of success. It’s easy to develop “diabetes burnout” or “diabetes distress” when dealing with it 24/7 starts to wear you down. At times like those, just take a deep breath and consider the alternative (that is, not being alive) and seek out emotional support from others if you need to. Sometimes it helps to just be able to vent your frustrations to someone else who understands and sympathizes with what you’re having to deal with every day. Lose the stress and the guilt over not being perfect with your blood glucose levels.

Finally, on days I would like to take a vacation from diabetes, I remember my grandfather’s uncle and that uncle’s two sons, all of whom died from type 1 diabetes in the 1910s before insulin was discovered in 1921. On those days, I simply try to be grateful that I have had even imperfect tools that have allowed me to live over 54 years with type 1 diabetes already. I’m also healthier than most people I know without diabetes, so living well is a success in my book!

Let’s Talk About Stress (and Ways to Manage It)

Life can just feel overwhelming sometimes. We all have stress in our lives from time to time, if not constantly for some people. What is stress exactly? Usually, we’re talking about a mental or emotional state, but it can also include physical stressors. The American Institute of Stress has a list of 50 common symptoms of stress.

A little stress once in a while is usually manageable for most people; it’s just when it gets to be too much or occurs too often that it can take a toll on your psyche or your body (or both). What can you do to lower excess stress? It largely depends on its cause.

On the mental or emotional side, you may feel stressed by having looming deadlines, dealing with kids, being a caregiver for an ailing parent, having financial problems, hating or losing your job, feeling academic pressures, dealing with two plus years of COVID-19, losing someone you love, having to manage a chronic disease (like diabetes), or even dealing with how you’re feeling about recent SCOTUS rulings—the possible list is nearly endless and unique to each person.

On the physical side, stressors include things like not sleeping long or well enough, getting sick (whether with a cold, the flu, COVID, or something else), having long COVID symptoms, not being able to manage chronic health conditions (like diabetes or high blood pressure), undergoing cancer treatments, or even simply pushing yourself too hard for too long (causing injuries or other physical damage). Even exercising too much can cause physical stress leading to injuries or cause you to get sick by depressing your immune system.

Our bodies have a physical response to any type of stressor. Acute stress can cause an increase in your heart rate and blood pressure, and you’ll likely also experience a rise in a hormone called cortisol, which can cause insulin resistance and higher blood glucose levels. Sustained high levels of cortisol can also cause you to gain weight, even if you’re not eating more.

Did you ever wonder why people reach for the ice cream container when they feel stressed? There are physiological reasons why that can actually help. Your mental or emotional stress levels can drop when you increase the brain hormones that activate your pleasure centers there. The main brain hormones that can help lower stress are dopamine and endorphins, all of which can be released by eating ice cream (and by other means).

Since being stressed can impact your ability to manage your daily activities and reach your goals, it’s really important to be able to find ways to manage it. (You can find plenty of resources online to help you find which stress management techniques work best for you; some of them are mentioned on the website for the American Institute of Stress). Personally, I used to have a mental list of natural and legal endorphin/dopamine-releasing activities that I thought undertaking about when my own emotional/mental stress levels were getting too high. Maybe you could try some of these:

Physical activity

  • Being active is my favorite stress management strategy, but it has its limits since too much activity can raise cortisol and cause overuse injuries. Even just taking a quick walk for a few minutes may help you lower your stress levels.

Sleep

  • It can be hard to get more sleep or sleep well when you’re stressed or sick. If you can, fit in a power nap to help clear your mind and lower your mental and physical stress.

Eating certain foods

  • Most fats, sweets, starchy foods, and chocolate can release dopamine in your brain, but all of these can raise your blood glucose and make you gain weight. Plus, the guilt that comes with overindulging can also increase stress! See if having just a bite or two and really savoring them will suffice to lower your stress.

Laughing

  • Yes, laughter really is the “best medicine,” but it can be hard to get yourself to laugh when you’re really stressed. Maybe try laughing at the absurdity of a situation that you’re finding yourself in and see if that helps.

Deep breathing or meditation

  • I’ve seen other people try these techniques with success, but they never work for me. (I’m too Type A to sit still long enough to breathe deeply for long or to meditate at all.) Maybe just take few minutes by yourself to decompress, if nothing else.

Sex

  • I find sex is better with the right partner, but that’s not always an option. Plus, it can be hard to really enjoy sex if you can’t get your mind off your stressors.

Smoking cigarettes

  • Nicotine binds to receptors in your brain just 7 seconds after you inhale, but smoking is definitely not good for your health. This was a running joke for me at one very stressful point in my life, though, when I was maxing out all the other dopamine-inducing techniques and would ask jokingly, “So, which brand of cigarettes should I try?”

All joking aside, it’s important to manage daily stress to keep it from impairing your ability to live life to the fullest. Realize your limitations in managing all of the stressors in your life (you seldom can). Instead, try to figure out which stress management techniques work for you. Use a combination of them or vary which you try on any given day or for each unique situation. Your long-term health and well-being are dependent on it!

My Diabetes Vacation?

You know what the hardest thing about having any type of diabetes is? You never get to take a vacation from it. (The same is true about most chronic health conditions.) Diabetes is unique, though, in that it generally impacts every aspect of living, from eating to exercising to sleeping and aging well.

I’m not complaining—just commenting about my life with type 1 diabetes for well over 50 years. In the early years, I did not have the capacity to check my blood glucose and could only guess at what it was doing. For that reason, I had to become very aware of my body’s responses to every morsel that I ate and any activity that I did (or didn’t) do, which to this day still helps me better predict how my body will respond. Ignorance was not bliss, though, and it was honestly a relief to be able to check my blood glucose when I finally started being able to.

When I first got a blood glucose meter back in the 1980s (after 18 years without one), I checked often and religiously tracked what I ate, drank, and did for more than a decade, which helped with understanding how my body responds and what to expect. Documenting its impact around the clock for decades, though, never allowed me to take a vacation from diabetes.  

Nowadays, some people may feel like they can get more of a vacation by having a continuous glucose monitoring (CGM) device that gives them a reading every five minutes. I wish that a CGM would let me take a mental vacation, but I personally end up getting more frustrated by the inaccuracies of my CGM, its frequent and nighttime alarms (that I can’t turn off), the time lag between CGM glucose values and actual blood glucose (a 6- to 20-minute delay), and feeling pushed to achieve perfect blood glucose values—which is hard to do with a chronic disease that affects metabolism and is impacted by hormones, stress levels, sleep quality, illnesses, and so much more.

Some people swear by insulin pumps but, again, I personally have been frustrated with using them due to infusion site issues (not delivering any insulin at times, leading my blood glucose to shoot up for hours), cost of pump supplies, insulin waste (as they hold way more than I could ever use before they need to be changed), and constantly having to wear something on my body. For these reasons, I’m not that excited about the hybrid closed-loop systems comprised of a pump and CGM that deliver basal insulin via programming and algorithms handled by a separate device. With such systems, you still have to decide how much insulin to give for meals and override the system’s settings to be able to exercise without going low, which is one of the biggest hurdles to having them fully automated. I also don’t trust CGMs to guide insulin delivery choices with how often mine has been off target.

So, for me, a true diabetes vacation is likely not coming anytime soon. The closest I get to one is going old school for a while with no CGM and no insulin pump. Don’t let anyone tell you that you absolutely have to have these devices to manage your blood glucose levels—I have the same very respectable A1C values without them as I can achieve with them—but also don’t abandon your blood glucose meter!

Sometimes my idea of a vacation from diabetes is just checking my blood glucose is 10 times a day instead of 288 (every five minutes)! Do whatever you need to do for your own peace of mind with diabetes and call it a vacation until an actual diabetes cure comes along.

Is It Better for Physical Activity to Be Continuous or Discontinuous?

Back when I started in exercise physiology, it was generally accepted that doing any aerobic activity continuously would give you greater fitness and health benefits. We compared moderate-intensity aerobic exercise (like walking, jogging, cycling, or swimming) with doing the same activity in shorter (but not necessarily harder) sessions or discontinuously. Until recently, the recommendation has been that people should exercise for at least 10 minutes at a time, and only people with a really limited capacity to be active were recommended to do shorter or discontinuous workout sessions.

Times have changed as we have learned more about different types and intensities of aerobic and other forms of training that can be beneficial, especially when it comes to management of blood glucose levels and overall health (1, 2). For instance, doing high-intensity interval training (HIIT) for half as much total time as a moderate-intensity continuous activity increases aerobic fitness at least as much, if not more, than the continuous one and has a similar impact on fasting insulin levels in adults with type 2 diabetes (3). Of course, not everyone can or wants to do harder intervals, but even doing the same total amount of the same intensity differently—such as doing three separate 10-minute sessions instead of one continuous 30-minute session—has the same impact on blood glucose levels in adults with prediabetes or diabetes (4).

Are there other equally beneficial ways to be active? Recently, a systematic review and meta-analysis with 27 studies (and a total of 635 adult participants) with and without diabetes looked at the impact of doing a single session of continuous aerobic activity versus accumulating the same amount of activity in much shorter bouts over the course of the day (5). Interestingly, they found that doing physical activity “breaks” that were mostly low- or moderate-intensity was more effective than doing a single continuous activity when it came to managing blood glucose after meals, even with no change in post-meal insulin levels. That means it may be possible to manage blood glucose simply by being more active all day long, even in short sessions, which gives people more options for becoming and staying more physically active to benefit their health and diabetes management when they have limited time or a lower capacity to exercise.

We have even learned in the past decade that not sitting for long periods of time can improve how metabolism works. Plenty of studies have now reported on the benefits of breaking up sedentary time with any type of physical movement (even standing), whether you have diabetes or not (6-8). Taking just a short (10-minute) walk after a meal can keep blood glucose levels from rising as much (9) and so can doing 3 minutes of activity every 20 minutes after a meal, and people with higher levels of insulin resistance to start with benefit the most (10).

The 2018 U.S. federal recommendations on physical activity (11) now reflect much of this new knowledge (available online at https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf). They state that “Adults should move more and sit less throughout the day. Some physical activity is better than none. Adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits.” Of course, the more you do, the more benefits you gain—at least up to a point—and adults can benefit from doing a variety of activities weekly that work on cardiorespiratory fitness, strengthen muscles and joints, increase flexibility, and improve balance and agility. Nonetheless, it may be time to implement a nationwide requirement that everyone get up and start moving after every meal. Just think how much that would improve our collective health!

References:

1.   Wu N, Bredin SSD, Guan Y, Dickinson K, Kim DD, Chua Z, et al. Cardiovascular Health Benefits of Exercise Training in Persons Living with Type 1 Diabetes: A Systematic Review and Meta-Analysis. J Clin Med. 2019;8(2).

2.   Pan B, Ge L, Xun YQ, Chen YJ, Gao CY, Han X, et al. Exercise training modalities in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis. Int J Behav Nutr Phys Act. 2018;15(1):72.

3.   Li J, Cheng W, Ma H. A Comparative Study of Health Efficacy Indicators in Subjects with T2DM Applying Power Cycling to 12 Weeks of Low-Volume High-Intensity Interval Training and Moderate-Intensity Continuous Training. J Diabetes Res. 2022;2022:9273830.

4.   Chang CR, Russell BM, Dempsey PC, Christie HE, Campbell MD, Francois ME. Accumulating Physical Activity in Short or Brief Bouts for Glycemic Control in Adults With Prediabetes and Diabetes. Can J Diabetes. 2020;44(8):759-67.

5.   Zhang X, Zheng C, Ho RST, Miyashita M, Wong SHS. The Effects of Accumulated Versus Continuous Exercise on Postprandial Glycemia, Insulin, and Triglycerides in Adults with or Without Diabetes: A Systematic Review and Meta-Analysis.  Sports Med Open. 2022;8.

6.   Gillen JB, Estafanos S, Williamson E, Hodson N, Malowany JM, Kumbhare D, et al. Interrupting prolonged sitting with repeated chair stands or short walks reduces postprandial insulinemia in healthy adults. J Appl Physiol (1985). 2021;130(1):104-13.

7.   Bailey DP, Maylor BD, Orton CJ, Zakrzewski-Fruer JK. Effects of breaking up prolonged sitting following low and high glycaemic index breakfast consumption on glucose and insulin concentrations. Eur J Appl Physiol. 2017;117(7):1299-307.  

8.   Dempsey PC, Owen N, Yates TE, Kingwell BA, Dunstan DW. Sitting Less and Moving More: Improved Glycaemic Control for Type 2 Diabetes Prevention and Management. Curr Diab Rep. 2016;16(11):114.

9.   Bellini A, Nicolò A, Bazzucchi I, Sacchetti M. Effects of Different Exercise Strategies to Improve Postprandial Glycemia in Healthy Individuals. Med Sci Sports Exerc. 2021;53(7):1334-1344.

10. Dempsey PC, Larsen RN, Winkler EAH, Owen N, Kingwell BA, Dunstan DW. Prolonged uninterrupted sitting elevates postprandial hyperglycaemia proportional to degree of insulin resistance. Diabetes Obes Metab. 2018;20(6):1526-30.

11. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, et al. The Physical Activity Guidelines for Americans. JAMA. 2018;320(19):2020-8.

Variety Is the Spice of Life—and of Physical Activity

I am a long-time believer in the benefits of cross-training when it comes to physical activity. Cross-training means varying your training mode from day to day: for example, on Monday, Wednesday, and Friday, you may do brisk walking and another aerobic exercise (like cycling, rowing, or swimming) on alternate days or resistance training. Doing a variety of activities not only helps you prevent overuse injuries (1), but also can be more motivating.

Since most of the physical activity guidelines—for people with and without diabetes—revolve around moderate to vigorous aerobic exercise and resistance training, what about doing other intensities of exercise? I often advocate alternating hard and easy training days, along with varying the pace of training even within a single exercise session, for best results, but fitness gains can also vary in both directions when you change up the intensity of activities. But do alternate or low-intensity ones count for cross-training, or are they not intense enough?

Whether or not an activity should count may depend on your goals. If your primary objective is to get more fit, doing anything that is moderate or higher in intensity is likely better for raising your aerobic or muscular fitness—although how well you respond depends in large part on your initial level of fitness (i.e., the lower it is, the more you gain from doing any activity at any intensity). Also keep in mind that training gains are activity-specific, meaning that you may be in great shape for walking or running and no shape at all for swimming or rowing. If your goal is more health-related, such as managing blood glucose or health issues, many lower-intensity or alternate activities may be even more appropriate to do than more intense ones.

Let’s take a closer look at some of these other activities. In this category, I would include a lot of less traditional ones, such as stretching, yoga, tai chi, qigong, and even table tennis.

  • Stretching and flexibility exercise:

Everyone loses flexibility with aging, but having diabetes can speed up those losses. Any exercise done to prevent or reverse this trend will help you in countless ways. Simply stretching your calves appears to be helpful in many ways (2). Years ago, we studied the impact of doing stretching with resistance training in adults with type 2 diabetes and found that it can increase the range of motion around a variety of joints (3). A more recent study looked at how calf-stretching may help prevent and treat diabetes-related foot ulcers (4), and who would not want to prevent those if they can? I personally have found that stretching my feet (the plantar fascia in particular) and ankles has really increased my flexibility when trying to touch my toes. Stretching all of your major muscles group is recommended at least 2 to 3 days per week.

  • Yoga:

Yoga has been frequently studied, but only recently have the studies on populations with diabetes had a high enough quality to be definitive. The findings are that yoga helps people with diabetes—when it comes to overall blood glucose levels (5) and fasting glucose and body mass index (6), even when compared to other higher-intensity exercise. It can even improve quality of life in this population (7) -and lower oxidative stress (8), which is associated with many diabetes-related health complications. So feel free to yoga away!

  • Tai chi or qigong:

The potential benefits of tai chi, a low-intensity activity that involves strength and stretching moves and only low-intensity aerobic training, are vast and include potential improvements in fasting blood glucose, certain blood lipid levels, and BMI (9). In fact, tai chi may be more effective than aerobic training for certain metabolic measures, such as A1C and HDL-cholesterol. In some instances, qigong may be even better than tai chi, but it differs by outcomes (10); however, many health improvements have been noted with this family of activities (11), including better cognition and balance (12). It may just be time to take up one of these activities in your spare time for added health benefits.

  • Table tennis:

Not many studies on this sport/activity have been done in people with diabetes, but we did one a while ago. In that one small study, playing table tennis for 30 minutes (against a ball robot) was as beneficial as walking after dinner when it came to measures like heart rate variability and mood, but self-paced walking (on a treadmill) had a slight edge when it came to lowering the spike in blood glucose after eating (13). As table tennis is a popular activity and competitive sport in many countries around the world, its potential health impacts should not be ignored. It may be time to dust off that table in your garage and grab a paddle after all.

Overall, doing a variety of physical activities in a given week is optimal—both for physical (joint/muscle/fitness level) and emotional health. So, try a new activity at any intensity level today, especially one that you find enjoyable.

References:

1.   Bales J, Bales K. Training on a knife’s edge: how to balance triathlon training to prevent overuse injuries. Sports Med Arthrosc Rev. 2012;20(4):214-6.

2.   Medeiros DM, Martini TF. Chronic effect of different types of stretching on ankle dorsiflexion range of motion: Systematic review and meta-analysis. Foot. 2018;34:28-35.

3.   Herriott MT, Colberg SR, Parson HK, Nunnold T, Vinik AI. Effects of 8 weeks of flexibility and resistance training in older adults with type 2 diabetes. Diab Care. 2004;27(12):2988-9.

4.   Maeshige N, Uemura M, Hirasawa Y, Yoshikawa Y, Moriguchi M, Kawabe N, et al. Immediate Effects of Weight-Bearing Calf Stretching on Ankle Dorsiflexion Range of Motion and Plantar Pressure During Gait in Patients with Diabetes Mellitus. Int J Low Extrem Wounds. 2021:15347346211031318.

5.   Gupta U, Gupta Y, Jose D, Mani K, Jyotsna VP, Sharma G, et al. Effectiveness of Yoga-based Exercise Program Compared to Usual Care, in Improving HbA1c in Individuals with Type 2 Diabetes: A Randomized Control Trial. Int J Yoga. 2020;13(3):233-8.

6.   Jayawardena R, Ranasinghe P, Chathuranga T, Atapattu PM, Misra A. The benefits of yoga practice compared to physical exercise in the management of type 2 Diabetes Mellitus: A systematic review and meta-analysis. Diab Metab Syndr. 2018;12(5):795-805.

7.   Cui J, Yan JH, Yan LM, Pan L, Le JJ, Guo YZ. Effects of yoga in adults with type 2 diabetes mellitus: A meta-analysis. J Diabetes Investig. 2017;8(2):201-9.

8.   Venugopal V, Geethanjali S, Poonguzhali S, Padmavathi R, Mahadevan S, Silambanan S, et al. Effect of Yoga on oxidative stress in type 2 diabetes mellitus: a systematic review and meta-analysis.  Curr Diabetes Rev. 2021 Apr 4. doi: 10.2174/1573399817666210405104335.

9.   Guo S, Xu Y, Qin J, Chen Y, You Y, Tao J, et al. Effect of tai chi on glycaemic control, lipid metabolism and body composition in adults with type 2 diabetes: A meta-analysis and systematic review. J Rehabil Med. 2021;53(3):jrm00165.

10. Li X, Si H, Chen Y, Li S, Yin N, Wang Z. Effects of fitness qigong and tai chi on middle-aged and elderly patients with type 2 diabetes mellitus. PLoS One. 2020;15(12):e0243989.

11. Zhang YP, Hu RX, Han M, Lai BY, Liang SB, Chen BJ, et al. Evidence Base of Clinical Studies on Qi Gong: A Bibliometric Analysis. Complement Ther Med. 2020;50:102392.

12. Cai H, Li G, Jiang S, Yin H, Liu P, Chen L. Effect of Low-Intensity, Kinect™-Based Kaimai-Style Qigong Exercise in Older Adults With Type 2 Diabetes. J Gerontol Nurs. 2019;45(2):42-52.

13. Colberg SR, Grieco CR, Somma CT. Exercise effects on postprandial glycemia, mood, and sympathovagal balance in type 2 diabetes. J Am Med Dir Assoc. 2014;15(4):261-6.

A True Story about a Cause of Slow Weight Gain in Diabetes

I recently had a personal experience with slow weight gain that is worth mentioning. It was concerning to me not only because my clothes were fitting tighter than I like, but also because I have generally been weight stable throughout my adult life. While many people have gained weight during COVID, I am lucky to live somewhere with weather conducive to exercising outdoors all year long. And as you know, I am an exercise physiologist and happily practice what I preach about being active.

However, during the past year when I slowly was gaining some weight, the cause was, at first, inexplicable to me. My weight was slowly creeping up about a pound a month over a six-month period. In my head, I went through all the possible reasons someone like me (who has type 1 diabetes) could be gaining weight:

  1. Taking too much insulin. This is always the first thing I consider. Needing to take more insulin can happen for a variety of reasons, including eating more, exercising less, going through stressful times (mental or physical), hormonal changes, and changing insulin types or timing. While I had changed my basal insulin from Lantus to Tresiba, that occurred six months before the weight gain started.
  2. Gaining muscle mass from exercise training. While gaining muscle from working out can certainly happen, I have been physically active throughout my adult life but since I had actually been exercising more (greater volume) during COVID times, not less, could it be that I was actually gaining some new muscle mass from training? I know from experience that this was highly unlikely for me, no matter how desirable it would have been. If anything, we’re all slowly losing muscle mass with each passing decade.
  3. Doing less daily movement. COVID times have also restricted people from doing many of the activities they normally undertake on a daily base, such as commuting to work or school and getting out of the house. Just having less daily movement can lead to slow weight gain, but in my case, I have been working from home for the past five years. My weight gain was not from doing less daily movement than normal.
  4. Having to treat too many hypoglycemic episodes. Training more and becoming more insulin sensitive can result in excess calorie intake from treating lows. When I changed my basal insulins, though, I actually started getting fewer nighttime lows and no longer needed a bedtime snack. Again, it did not appear to be a likely cause for me specifically.
  5. Hormonal changes and weight gain associated with aging. Everyone goes through hormonal changes with aging—even men—and it is often blamed for the middle-aged spread many people have. However, aging alone is not a cause of weight gain if you’re taking in the right amount of calories daily. I am finally old enough to be going through the menopausal stage of my life, and it certainly has impacted my insulin needs some, but my personal experience has been to need less insulin, not more, without the normal female monthly cycles and cyclic increases in insulin resistance. Again, I was having trouble blaming one year’s weight gain on age-related changes.
  6. Consuming empty calories through alcohol intake. My husband and I undeniably have been trying our best to help support our local wineries by buying and drinking more wine than normal, especially since the pandemic started. Nevertheless, we still draw the line at one 5-oz glass of wine daily, which is only about 100 calories, and my wine intake has been more or less consistent for longer than the past year.
  7. Taking in too many calories for other reasons. I grew up with diabetes before there were blood glucose meters and many insulin choices, and I have always been careful about what I eat since I have to balance everything with insulin. At my former university, I also taught fitness-related nutrition for almost two decades, so I understand diet, calories, and body weight connections. Taking in too many calories for any reason—even if it’s just 50 a day—can result in weight gain over time. In fact, an excess of just 50 calories a day (whether it’s from eating more or exercising less, or both) can potentially cause you to gain 5 pounds in a year. Still no immediate answers there for me, though.

In my case, the “Eureka!” moment came last fall when I was complaining to my husband about my slow weight gain. He could have looked at me and said, “Honey, you’re beautiful at any weight!” and I would have laughed in his face. Instead, he said, “I think it’s the chocolate.”

Admittedly, I have always had a weakness for dark chocolate. Even with diabetes, I can barely feel the impact of eating any on my blood glucose, and it hardly ever requires extra insulin. What I realized had been happening, though, is that I was simply eating too much of it. A few bites of Bark Thins (bought from Costco in the large economy bags) here or five dark chocolate almonds there really adds up more than you give those (mostly) empty calories credit for!

So, I went cold turkey and cut out all dark chocolate candy that day. Don’t get me wrong—I have a chocolate tooth. I have continued to drink a half packet of sugar-free hot cocoa mix each morning with breakfast (I don’t like coffee—long story there stemming from my childhood), but I started replacing my after-dinner dark chocolate candy (undetermined amount, but clearly too many calories) with a single sugar-free frozen Fudge Pop (40 calories), which takes much longer to eat and satisfies my chocolate tooth. Life is just better with some chocolate in it.

Within three months of dropping dark chocolate—without any other dietary changes—my weight gain had reversed and I was back down to my previous, more comfortable body weight, where I have plateaued and like to be. The amazing thing is that I didn’t give up wine or eating other things I like or make myself try to exercise even more or go on a diet: I just simply gave up some extra, uncounted calories from dark chocolate, my intake of which was hard to pin down.

If you’re unhappy with your body weight or gained some extra during COVID, maybe now is the time to look at your own dietary patterns and/or exercise participation and figure out what may be causing your calorie imbalance. There are so many possibilities, but I will leave it up to you to figure out your own way to rebalance the intake-output calorie scale that may have a big impact on your weight or your health. Happy hunting!

A New ACSM Consensus Statement Brings You the Latest on Being Active with Type 2 Diabetes

I recently co-chaired a new consensus statement from the American College of Sports Medicine (ACSM) that is an update from the 2010 joint ACSM/American Diabetes Association position statement on physical activity/exercise for individuals with type 2 diabetes (T2D) (1). A lot more research has been conducted in the ensuing decade since the joint position statement was published, and this new consensus statement (2) provides a summary of the current evidence.

In short, it recommends that people with T2D (or prediabetes) engage in physical activity regularly and reduce their sedentary time. Various types of physical activity and planned exercise can greatly enhance the health and glycemic management of individuals of all ages with T2D, however, including flexibility and balance exercise in adults. The greater emphasis on these latter two types is the result of many studies showing their importance in preventing loss of range of motion around joints while aging with diabetes. They also lower the incidence of falls and injuries, even in people with peripheral nerve damage from long-standing diabetes in their feet and lower extremities.

The new topics covered this time around include a discussion of the importance of physical activity around bariatric surgery, the impact of the timing of a bout of exercise, the merits (and potential detriments) of high-intensity interval training, how being regularly active affects mental health and cognitive function, nutritional concerns around activity, and disparities in access and barriers to physical activity. Lifestyle interventions that include physical activity, dietary changes, and possible weight loss remain important approaches in the management of T2D and cardiovascular disease risks.

What else is important to know? Almost all of the conclusions from the 2010 joint position statement are still valid. The following is a synopsis of the findings of the consensus statement and its current physical activity recommendations:

  • Regular aerobic exercise training improves glycemic management in adults with T2D. Adults who exercise regularly spend less daily time with hyperglycemia (elevated blood glucose) and experience a 0.5 to 0.7 percent drop in A1C.
  • When resistance training is high-intensity, it bestows greater beneficial effects than low-to-moderate-intensity training when it comes to lowering A1C and insulin levels. (However, doing any resistance training is always better than none.)
  • Exercising after meals reduces blood glucose levels regardless of the intensity of activity or the type done and doing 45 minutes or more provides the most consistent benefits.
  • Small “doses” of any type of physical movement done throughout the day to break up sitting time help lower glucose and insulin levels after meals, albeit modestly, particularly in individuals with insulin resistance and a higher body mass index (BMI).
  • Weight loss—when accomplished through lifestyle changes in diet and activity—of more than 5 percent of total body weight seems to be necessary for the most beneficial effects on A1C, blood lipids, and blood pressure in adults with T2D.
  • To reduce visceral (deep abdominal) fat, a moderately high volume of exercise, i.e., using up ~500 calories per day through activity, done 4 to 5 days per week may be needed.
  • In youth with T2D, following intensive lifestyle changes while taking metformin is about as effective as metformin by itself for managing overall blood glucose levels. (However, lifestyle improvements are still recommended for a variety of reasons.)
  • Although research on this topic is limited, it is still recommended that youth and adolescents with T2D diabetes meet the same physical activity goals set for youth in the general population.
  • Pregnant women with and without diabetes should participate in at least 20 to 30 minutes of moderate-intensity exercise most days of the week.
  • Individuals with T2D using insulin or insulin secretagogues are advised to supplement with carbohydrate (or reduce insulin, if possible) as needed to prevent hypoglycemia (low blood glucose) during and after exercise.
  • Participating in an exercise program before undergoing bariatric surgery may enhance surgical outcomes, and after surgery, regular exercise confers additional benefits.

While much more new and relevant information is available in this consensus statement, you will have to read the rest for yourself! Find the statement online: https://journals.lww.com/acsm-msse/Fulltext/2022/02000/Exercise_Physical_Activity_in_Individuals_with.18.aspx.

References:

  1. Colberg SR, Albright AL, Blissmer BJ, Braun B, Chasan-Taber L, Fernhall B, et al. Exercise and type 2 diabetes: American College of Sports Medicine and the American Diabetes Association: joint position statement. Exercise and type 2 diabetes. Med Sci Sports Exerc. 2010;42(12):2282-303. doi: 10.1249/MSS.0b013e3181eeb61c.
  2. Kanaley JA, Colberg SR, Corcoran MH, Malin SK, Rodriguez NR, Crespo CJ, et al. Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine. Med Sci Sports Exerc. 2022;54(2):353-68. doi: 10.1249/mss.0000000000002800. PubMed PMID: 35029593.

Starting Out the New Year and Getting Rid of Type 2 Diabetes?

I recently was asked about the latest research on the reversal of type 2 diabetes—both bariatric and non-bariatric solutions—and it made me wonder about the mechanisms of this possibility and what role being active may play in it. Each new year always brings a whole host of resolutions that people make focused on losing weight, getting more fit, and becoming healthier. Especially with all the COVID-related pounds I have heard about people gaining (1), I expect these resolutions to be out in full force at the start of 2022. But how effective will they be long-term, and is the reversal of type 2 diabetes a realistic resolution to make?

Getting blood glucose levels back to normal (to the point where it appears you no longer have type 2 diabetes) may be possible for many, but we also know that hyperglycemia can return if this “reversal” was accomplished through lifestyle improvements when people backslide into less favorable lifestyle habits. Complete remission may be harder to accomplish in people who have had type 2 diabetes for longer as they can permanently lose some of the insulin-making capacity of their pancreatic beta cells (2).

Research on diabetes reversal relying on bariatric surgery has been somewhat more optimistic, and bariatric surgery is now considered the most effective way to improve glycemic management and achieve diabetes remission long-term (3, 4). That said, pre- and post-operative lifestyle changes including regular physical activity are always recommended. Aerobic exercise training following surgery may further enhance weight maintenance, glycemic management, and insulin sensitivity (5-7), and resistance exercise done post-surgery may reverse muscle strength deficits frequently observed after bariatric surgery (8) and help prevent some bone loss  (9, 10).    

As for the reversal of type 2 diabetes without surgery, interventions appear to be focused on weight loss. In a recent study on remission of type 2 diabetes (the DiRECT study), adults ages 20 to 65 who had been diagnosed within the prior six years and not taking insulin followed a 12-month intervention that involved extensive dietary changes but not physical activity (11). In that trial, almost half of participants achieved remission (normal blood glucose and not taking any diabetes medications), with no remission among those who gained weight and the greatest success rate among those who lost the most (86% remission in the participants who lost 15 kg or more). In a two-year follow-up, remission was sustained for more than a third of them, with a remission rate of 64% among those who maintained at least a 10-kg weight loss (12). In my opinion, that is still not that great, especially since most of the success appeared to rely on being able to keep the lost weight off (and we all know how hard that is).

That brings me back to physical activity and its potential role. It appears that remission of type 2 diabetes—at least in those with a more recent onset—is most closely tied to abnormal fat deposits in the pancreas and in the liver (13). Here is where physical activity can play a dramatic role. Exercise training improves whole-body insulin sensitivity but, even more importantly, even just two weeks of exercise training improves beta-cell function in adults with prediabetes and type 2 diabetes and decreases pancreatic fat (14). Substantial weight loss at the time of diabetes diagnosis may work best to prevent loss of pancreatic beta-cell capacity (2), but staying in remission also likely requires maintenance of that lost weight, which we know is more readily accomplished by becoming and remaining physically active (15, 16).

Moreover, both aerobic and resistance training have been shown to reduce ectopic abdominal fat (i.e., visceral, liver, pancreatic, and other abnormal fat deposits) best (14, 17, 18), so why not get and stay more physically active this year? It is the best chance you have for accomplishing your 2022 resolution to get rid of your type 2 diabetes. If getting regularly active is not entirely successful in normalizing your blood glucose levels, at least it will get you closer, and you will have a healthier and happier year and life ahead. Just get up and get moving for the best results.

References:

  1. Ruissen MM, Regeer H, Landstra CP, Schroijen M, Jazet I, Nijhoff MF, et al. Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic. BMJ Open Diabetes Res Care. 2021;9(1).
  2. Taylor R, Al-Mrabeh A, Zhyzhneuskaya S, Peters C, Barnes AC, Aribisala BS, et al. Remission of Human Type 2 Diabetes Requires Decrease in Liver and Pancreas Fat Content but Is Dependent upon Capacity for β Cell Recovery. Cell Metab. 2018;28(4):547-56.e3.
  3. Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Capristo E, et al. Metabolic surgery versus conventional medical therapy in patients with type 2 diabetes: 10-year follow-up of an open-label, single-centre, randomised controlled trial Lancet. 2021;397:293-304.
  4. Schauer PR, Bhatt DL, Kirwan JP, Wolski K, Aminian A, Brethauer SA, et al. Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 5-Year Outcomes. N Engl J Med. 2017;376(7):641-51.
  5. Coen PM, Tanner CJ, Helbling NL, Dubis GS, Hames KC, Xie H, et al. Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity. J Clin Invest. 2015;125(1):248-57.
  6. Dantas WS, Roschel H, Murai IH, Gil S, Davuluri G, Axelrod CL, et al. Exercise-Induced Increases in Insulin Sensitivity After Bariatric Surgery Are Mediated By Muscle Extracellular Matrix Remodeling. Diabetes. 2020;69(8):1675-91.
  7. Mundbjerg LH, Stolberg CR, Cecere S, Bladbjerg EM, Funch-Jensen P, Gram B, et al. Supervised Physical Training Improves Weight Loss After Roux-en-Y Gastric Bypass Surgery: A Randomized Controlled Trial. Obesity (Silver Spring). 2018;26(5):828-37.
  8. Oppert JM, Bellicha A, Roda C, Bouillot JL, Torcivia A, Clement K, et al. Resistance Training and Protein Supplementation Increase Strength After Bariatric Surgery: A Randomized Controlled Trial. Obesity (Silver Spring). 2018;26(11):1709-20.
  9. Diniz-Sousa F, Veras L, Boppre G, Sa-Couto P, Devezas V, Santos-Sousa H, et al. The Effect of an Exercise Intervention Program on Bone Health After Bariatric Surgery: A Randomized Controlled Trial. J Bone Miner Res. 2021;36(3):489-99.
  10. Murai IH, Roschel H, Dantas WS, Gil S, Merege-Filho C, de Cleva R, et al. Exercise Mitigates Bone Loss in Women With Severe Obesity After Roux-en-Y Gastric Bypass: A Randomized Controlled Trial. J Clin Endocrinol Metab. 2019;104(10):4639-50.
  11. Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet. 2018;391(10120):541-51.
  12. Lean MEJ, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie L, et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol. 2019;7(5):344-55.
  13. Petrov MS, Taylor R. Intra-pancreatic fat deposition: bringing hidden fat to the fore. Nat Rev Gastroenterol Hepatol. 2021 Dec 8. (Online ahead of print) PubMed PMID: 34880411.
  14. Heiskanen MA, Motiani KK, Mari A, Saunavaara V, Eskelinen JJ, Virtanen KA, et al. Exercise training decreases pancreatic fat content and improves beta cell function regardless of baseline glucose tolerance: a randomised controlled trial. Diabetologia. 2018;61(8):1817-28.
  15. Thomas JG, Bond DS, Phelan S, Hill JO, Wing RR. Weight-loss maintenance for 10 years in the National Weight Control Registry. Am J Prev Med. 2014;46(1):17-23.
  16. Friedenreich CM, Ruan Y, Duha A, Courneya KS. Exercise Dose Effects on Body Fat 12 Months after an Exercise Intervention: Follow-up from a Randomized Controlled Trial. J Obes. 2019;2019:3916416.
  17. Honkala SM, Motiani KK, Eskelinen JJ, Savolainen A, Saunavaara V, Virtanen KA, et al. Exercise Training Reduces Intrathoracic Fat Regardless of Defective Glucose Tolerance. Med Sci Sports Exerc. 2017;49(7):1313-22.
  18. Bacchi E, Moghetti P. Exercise for hepatic fat accumulation in type 2 diabetic subjects. Int J Endocrinol. 2013;2013:309191.

Q&A with Dr. Sheri Colberg: Part 2

I recently gave a webinar for the American College of Sports Medicine (and Technogym) that reached almost 1,200 participants in real time. You can watch the webinar, titled “The Role of Physical Activity in Type 2 Diabetes Management and Prevention,” posted on Youtube.

While the Q&A portion was done live, it was not included in the webinar recording. Plus, there were many additional questions for which there was no time to discuss. This article addresses the second half of those questions (the rest were answered in November 2021).

Q: Please mention blood sugar level prior to as well as fluid and hydration intake prior to ANY exercise is crucial to predict glycemic response…. regular blood glucose checks are key until you know how they respond.

A: The guidelines are that you should not begin exercise with a blood glucose >250 mg/dL (13.9 mmol/L) with moderate or high levels of blood or urinary ketones. If you don’t usually test for ketones, just make sure you have enough insulin “on board” to counterbalance the glucose-raising hormones that get released during physical activity. The harder the exercise is, the more of these hormones get released.

The guidelines also suggest that people should use caution during activities when starting with a blood glucose >300 mg/ dL (16.7 mmol/L) without excessive ketones, stay hydrated, and only begin if feeling well. For instance, if you take insulin and just ate a big meal, exercising right after when you may be experiencing a spike is usually okay because you have enough insulin in your body to bring the glucose levels down with activity.

As for hydration, drink adequate fluids before, during, and after exercise, as well as avoid exercising during the peak heat of the day or in direct sunlight to prevent overheating. These precautions are particularly important when someone has been experiencing hyperglycemia (elevated blood glucose levels) that can lead to dehydration or if someone has autonomic (central) nerve damage that can impair normal heat dissipation during exercise.

Q: What are your recommendations for glucose testing before, after or during exercise?

A: It really depends on the individual. Adults with type 2 diabetes not taking insulin or sulfonylurea oral medications may not need to check because their blood glucose is unlikely to drop too low during activities—but they may want to check to be motivated by its ability to lower blood glucose, especially during post-meal spikes.

If you use insulin, it is important to check before, occasionally during, and even at varying intervals of time after activities to prevent both lows and highs and to treat them more quickly. Frequent monitoring also helps with establishing usual patterns, trends, and responses that make it easier to predict what insulin regimen or food changes may be needed to keep blood glucose levels balanced, especially you may be prone to developing late-onset hypoglycemia following an activity that is particularly long or intense. 

Q: In order to avoid exercise-induced hypoglycemia, what are the normal values of glucose monitoring before starting exercise? Is there a target glycemic range that you would recommend for those with Type 1 diabetes to begin exercise to prevent hypo during activity? Also, how can people recognize and respond to hypoglycemic reactions?

A: A good starting blood glucose level can vary with the activity, time of day, and normal responses. Most people like to start in the range of 70 to 180 mg/dL (3.9 to 10.0 mmol/L), but it really depends. For example, if you’re going to do early morning exercise (before insulin or food), your blood glucose may raise due to the higher levels of insulin resistance at that time of day. Many people actually choose to exercise then so that their risk of going low is minimal. However, others prefer to exercise with slightly more insulin on board (but not too much) later in the day to avoid exercise-related highs, especially when doing more intense workouts. Some people actually give small amounts of insulin prior to doing intense early morning workouts to prevent going too high.

As for hypoglycemia, it can have a variety of symptoms, including shakiness, visual spots, lethargy, extreme fatigue, and more. To make it more challenging, the symptoms can vary by the person and by the activity or time of day. Learn to recognize your own symptoms by confirming your blood glucose levels whenever any symptoms arise. Anything with glucose works fastest to treat a low, but you can use a variety of carbohydrate sources and follow up with snacks with a balance of carbs, protein, and fat if lows tend to persist or recur over time.

Q: What resources would you recommend for additional information regarding clinical exercise programming with respect to common diabetes medications?

A: There are two position/consensus statements with compiled information about being physically active with diabetes that would particularly useful when it comes to diabetes medications and their impact on physical activity. One is an American Diabetes Association position statement from 2016 (PMID: 27926890), and the other is a consensus statement on type 1 diabetes from 2017 (PMID: 28126459).

Particularly for anyone using insulin or taking sulfonylureas (and possibly meglitinides within 2-3 hours of physical activity), it is important to carry rapid-acting carbohydrate sources during activities to treat hypoglycemia and have glucagon available to treat severe hypoglycemia (if you are prone to developing it).

Q: Diabetes type 2 has been related to intramyocellular lipid accumulation. As fat oxidation is optimized at a low exercise intensity, would you recommend low exercise intensity over high intensity exercise for patients with diabetes?

A: No. Any intensity of exercise that someone with type 2 diabetes can do is fine. While it is true that slightly more fat is used during lower intensities compared to higher ones, the primary fuel used by the body during most moderate or higher-intensity work is carbohydrate. Fat is the primary fuel during all recovery periods. Intramyocellular lipids, therefore, are the primary fuel used during periods of rest, which is most of the time. Just try to maximize your total calorie expenditure from physical activity without worrying about exercise intensity. (In other words, completely ignore anything that tells you that you are in a “fat burning range” as it is incorrect and irrelevant.)

Q: What precautions need to be taken if there is peripheral neuropathy?

A: It is generally recommended that people with moderate to severe peripheral neuropathy (loss of sensation in the feet) limit or avoid activities that may cause foot trauma, such as prolonged hiking, jogging, or walking on uneven surfaces. For them, it may be more appropriate to engage in non-weight-bearing exercises (e.g., cycling, chair exercises, swimming); however, they should avoid aquatic exercise with unhealed plantar surface (bottom of the foot) ulcers. It is also important to check feet daily for signs of trauma and redness. Other precautions include choosing shoes and socks carefully for proper fit and wearing socks that keep feet dry, such as some of the newer athletic socks that are polyester-cotton blends. Finally, neuropathy can affect both gait and balance, so they should avoid activities requiring excessive balance ability.

Q: I work with many folks who have kidney failure due to diabetes. Are there any precautions even though the client has been medically cleared?

A: Yes, the main precautions for these individuals revolve around avoiding exercise that causes excessive increases in blood pressure, such as heavy weight lifting, high-intensity aerobic exercise, and anything that causes breath-holding. For most, high blood pressure is common, and lower intensity exercise may be necessary to manage blood pressure responses and fatigue. The good news is that light to moderate exercise is possible during dialysis treatments if electrolytes are managed properly. A recent study showed that people on dialysis can safely engage in aerobic, resistance, or combined training with good outcomes on fitness, blood pressure, and metabolic function (PMID: 31865607).

Q: One of the complications you mentioned was peripheral arterial disease. The exercise pattern is less in these individuals. What do you think in that aspect when we can’t do higher intensity exercise what pattern should we focus?

A: Peripheral artery disease occurs when significant amounts of plaque are present in the blood vessels supplying the legs and feet. This blockage can cause pain and leg cramps, particularly during harder exercise, due to a reduced circulation and supply of blood and oxygen to those peripheral areas. While it may appear that exercise makes things worse, given the pain often associated with it, the opposite is true. It can actually improve circulation with formation of new, collateral blood vessels.

In general, the intensity of activity mainly impacts the recruitment of additional muscle fibers, specifically faster twitch fibers that are more anaerobic in nature than aerobic. Although fitness gains may be lesser with lower-intensity activities, doing anything at a low or moderate intensity still confers many health benefits, including increasing blood flow to areas with some artery blockage and enhancing oxygen consumption in engaged muscles (PMID: 28385410). Doing activities at any intensity that is possible, therefore, should be encouraged, and walking is fine for most people to engage. People should be encouraged to try alternate activities when pain in their legs is more severe or intolerable during a given activity. 

Q: Which fitness trackers monitor blood glucose levels and how does this work?

A: If discussing only FDA-approved glucose monitors, at the current time a person has to wear a separate continuous glucose monitoring (CGM) device like the latest ones from Dexcom that can transmit its readings to a fitness monitor, such as select Apple or Fitbit smartwatches, or to apps like the one associated with Fitbit or other trackers. A compatible smartphone is required to display data on an Apple Watch, and the Freestyle Libre CGMs work through a linked phone app as well. This connectivity is currently being updated and enhanced, so check the latest devices for specifics on which ones connect and how to set them up.

Q: Do you have any apps you recommend to track exercise?

A: There are so many different apps, and most of the latest smartphones have accelerometers in them that can track steps or distances traveled. I use one called “Map My Walk” that tracks most types of activity (not just walks) and gives distance, time, and more. Many others also estimate calorie use. It really depends on what data sets are most important to you.

Check back last month for Part 1 of this webinar-related Q&A!

Q&A with Dr. Sheri Colberg: Part 1

I recently gave a webinar for the American College of Sports Medicine (and Tcchnogym) that reached almost 1,200 participants in real time. You can watch the webinar, titled “The Role of Physical Activity in Type 2 Diabetes Management and Prevention,” posted on Youtube.

While the Q&A portion was done live, it was not included in the webinar recording. Plus, there were many additional questions for which there was no time to discuss. This article addresses the first half of those questions, and the rest will be answered in early December 2021.

Q: Can you speak to the ability or inability to “cure” T2D? Does it have to do with the loss of the pancreatic beta cells?

A: Yes, it has generally been shown that new-onset type 2 diabetes is easier to “reverse,” meaning that blood glucose levels can be so well managed that it appears diabetes has been cured. Over time, a loss of some insulin-making capacity occurs in people with long-standing T2D, particularly if it has not been well-managed, related both to the impairment of pancreatic β-cell function and the decrease in β-cell mass. (PMID: 27615139)

Q: Isn’t insulin resistance now found to be in T1DM as well?

A: Yes, anyone can develop insulin resistance, and it occurs in at least a third of people with type 1 diabetes as well, although it is not always associated with excess weight gain or overweight. Since people with T1D lack insulin due to the body’s own immune system killing off the pancreatic β-cells, greater resistance increases the total doses of insulin needed (whether injected, pumped, or inhaled). Thus, they have developed characteristics of both types and have “double diabetes.” (PMID: 34530819)

Q: Under lifestyle goals, would you include stress management?

A: Stress management was not assessed in the large multi-center clinical trials on type 2 diabetes prevention, but mental stress can certainly raise blood glucose levels due to the greater release of glucose-raising hormones like cortisol and adrenaline. It certainly would be beneficial to address better ways to manage mental stress as part of lifestyle goals for optimal blood glucose outcomes. (PMID: 29760788)

Q: As each person has their own limitations how important is it to get a physician clearance and exercise guidelines before working with the client?

A: It really depends on the person’s circumstances. How intense will the planned activities be? Is the person currently sedentary? Has he/she been getting annual checkups to monitor blood glucose management and to check the status of any complications? Does he/she have diabetes-related or other health complications that could be worsened by physical activity? The lower the intensity, the more active an individual has been, and the lower the risk for cardiovascular complications, the less likely medical clearance is absolutely necessary.

The latest ACSM Consensus Statement on activity and T2D will be released in early 2022 in Medicine & Science in Sports & Exercise and states, “For most individuals planning to participate in a low- to moderate-intensity physical activity like brisk walking, no pre-exercise medical evaluation is needed unless symptoms of cardiovascular disease or microvascular complications are present. In adults who are currently sedentary, medical clearance is recommended prior to participation in moderate- to high-intensity physical activity.”

Q: Can flexibility training be used for warmups, or do you recommend it only after the workout?

A: While it is possible to do flexibility training at any point during a workout, joints tend to have a greater range of motion after blood flow to those areas has been increased with a light or short aerobic warmup. It may be prudent to do a quick aerobic warmup, some stretching, the full workout, and then more extensive stretching afterwards for optimal results.

Q: Was there any particular protocol for strength training? sets, reps, periodization? What is considered “intense” resistance work? Would fatigue based off of several sets of moderate intensity be recommended then?

A: That is a tough question, and it depends on who you ask. I have seen a lot of debate over the optimal strength training protocol during the many years I have been in the exercise/fitness world. If people are just starting out with resistance training, they will gain from doing even a minimal amount of training.

Starting out with 1-3 sets of 8 to 10 main exercises that work all of the large muscles groups at a light to moderate intensity is considered appropriate for most older or sedentary adults, many of whom have joint limitations or health issues. Moderate intensity is considered 50%-69% of 1-RM (1 repetition maximum) and vigorous is 70%-85% of 1-RM. Both intensity (fewer reps at a higher intensity) and the number of sets (3-5) or days of training (starting at 2, progressing to 3 nonconsecutive days) can increase over 2 to 3 months. Periodization is usually not undertaken by older adults, but may be appropriate for younger, fitter ones.

Q: Do you have any insight or are aware of any studies that involve high intensity (%1-RM) resistance training and T2DM? Or any studies that compare resistance training volume (Sets x Reps x Load)?

A: Some older studies have determined that glycemic management is improved by supervised high-intensity resistance training in people with type 2 diabetes (PMID 12351469). Others have also found that home-based (and, therefore, unsupervised) resistance training results in a lesser impact on blood glucose levels, likely due to reductions in adherence and exercise training volume and intensity (PMID 15616225).

Q: I’m still confused about glucose response to acute exercise. Which is better if you want to bring down your BG right now? Can you speak to the possibility of increased blood sugars with intense aerobic exercise?

A: Most light-to moderate-intensity aerobic exercise will lower blood glucose levels, assuming that some insulin is present in the body. (People who are very insulin deficient may have a rise in blood glucose from doing any activity.) Any activity that gets up into the intense/vigorous range, even if only during occasional intervals, has the potential to raise blood glucose due to a greater release of glucose-raising hormones during the activity. This is particularly true if the activity is short and intense. In individuals with any type of diabetes, declines in blood glucose during high-intensity interval exercise are smaller than those observed during aerobic exercise.

That said, if someone wants to lower blood glucose right now with exercise, it also depends on the timing of exercise. Doing something light to moderate for at least 10 to 30 minutes is the best bet, particularly after a meal when insulin levels are generally higher. Avoid doing intense aerobic or heavy resistance training as those may have the opposite effect. For early morning exercise, any intensity can potentially raise blood glucose due to higher levels of insulin resistance then and lower circulating levels of insulin in the body.

Q: I had an endocrinologist say that long runs or walks are better, and another one said to do a bit of weights.

A: Which activities someone chooses to do should depend on the goal of the training. Is it increased fitness, lowering blood glucose levels acutely, or gaining strength and improving overall blood glucose management? Long, slow aerobic training does have the benefit of increasing cardiorespiratory fitness and lowering blood glucose levels (in most cases). Resistance training, on the other hand, increases muscular strength and endurance and helps people gain and preserve muscle mass, which is where most carbohydrates are stored in the body. It may not, however, lower blood glucose levels, at least not acutely.

Both have their place in a weekly training regimen. Insulin resistance is lowered for 2 to 72 hours following a bout of aerobic training. Resistance training has more of a long-term impact on insulin action by enhancing carbohydrate storage capacity. The best advice is to do some aerobic training at least every other day and some resistance training at least 2, and preferably 3, nonconsecutive days per week. These activities can be done on the same days or different ones.

Tune in for Part 2 of this webinar-related Q&A coming soon!