Athletic Injuries and Aging—It Isn’t for Sissies

I recently overheard an older woman in my local public pool locker room recounting a story to a friend about developing plantar fasciitis, a common foot arch overuse injury. To my knowledge, she did not have diabetes (which could have put her at higher risk for developing any and all overuse and joint injuries), but she looked to be in her late 60s or early 70s.

Her story was that her foot problems had come on suddenly, and the only thing she had done differently was walk on the beach and go up and down about 150 steps to access the sand. She had been a bit sore in her leg and butt muscles the day after the beach walk, and then her plantar fasciitis came on shortly thereafter. She told her friend that she and her husband cycle three days a week and swim on the other days, so they are regularly active but just hadn’t been walking the beach or the steps to reach it for about six months.

Her exasperated comment was, “So, now I’m at the age where I’m getting injured from just walking?”

Her story resonated with me, given my own recent experiences with having various overuse injuries that come out of seemingly nowhere. This past weekend, I did the same step and beach walk as that older woman (who has at least a decade on me). The walk was only about 3 miles at a normal pace, but the sand was fairly slanted due to the tides and our timing. The next day when my husband and I went for another walk on regular level surfaces, my left hip joint was hurting and the pain has persisted for a couple days. Yesterday, I tried doing a hip abductor resistance training machine and could barely move any weight with my left side—all from just beach walking!

Both of our stories just go to show you that training is very specific for the joints and muscles used and the manner in which they are worked. Cycling does not train you for swimming, and even walking on flat surfaces (which I do regularly) does not stress your joints and muscles the same way as walking on a slanted beach (which I had not done for at least 5 months).

Generally, overuse injuries are caused by repetitive microtrauma that leads to inflammation and/or local tissue damage. Unfortunately, this damage can result in overuse conditions like tendinitis or tendinosis, stress fracture, synovitis, entrapment neuropathies, ligament strains, or myositis.

When are you most likely to develop such injuries? They’re more common whenever you change the mode, intensity, or duration of your exercise training. Changing your normal workouts causes your body to respond to the repetitive overload on tissues that are trying to adapt to the new or increased demands. When there is a mismatch between overload and recovery, you can end up with tissue breakdown at the cellular level, which can lead to an acute injury or an overuse one.

What can you do to combat getting such overuse injuries, especially when you’re busy and already fitting in as much activity on a daily/weekly basis as you can? Here are a few suggestions:

• Ease into different and/or new activities slowly and don’t overdo it when you start out until your body has time to adapt and adjust.
• Give your irritated joints time to heal before you try the aggravating activity again (in other words, don’t add insult to injury by trying them again until the pain is better).
• Work on getting and maintaining full motion around the joints you tend to aggravate as their flexibility is important to avoid injuries.
• Incorporate exercises into your resistance training routine that strengthen all the muscles around your joints to balance them out, especially any joints you have injured previously.
• Work on your form or mitigate other aggravating factors—such as getting newer or different shoes, especially if you have a lot of miles on your current pair or need a different type to walk on the beach.

As they always say, aging isn’t for sissies. But I also always add, “But it beat the alternative.” Stay active, stay well, and live a long and healthy (and hopefully mostly injury-free) life.

My Love-Hate Relationship with CGM

I currently have a Dexcom G6 continuous glucose monitoring (CGM) device, and I have to say that I both love and hate it. Why, you ask? It’s complicated.

Nowadays, it is increasingly common for people with type 1 diabetes to have CGMs, such as the latest ones from Dexcom, Medtronic, and Senseonics, or intermittent ones like Abbott Freestyle Libres that have to be scanned to give the glucose reading. To keep it simple, they are all generally referred to as “CGM.”

If you’re new to diabetes or have only had it for less than a decade, you may have started out with a CGM to monitor your glucose levels and never question using one. You need to know what your glucose level is, right? My path to CGM has been vastly different, which may at least partially explain my love-hate affair with using one.

I started out with urine testing in 1968 when I was diagnosed with type 1 diabetes at age 4. Some of my earliest memories are putting 5 drops of urine and 10 drops of water into a test tube, followed by a tablet that bubbled up to a color ranging from blue (no sugar) to bright orange (lots of sugar). I remember having a lot of orange test tubes, which always made me feel guilty. This method was all we had back then. Unfortunately, it could only tell you that your blood glucose had been high enough at some point (~200 mg/dL) for excess sugar to spill over into your urine, but not a thing about your actual, real-time glucose level.

In 1986, after having lived with diabetes for 18 years using only how I felt as my glucose guide, I got my first fingerstick blood glucose meter. What a revelation that was! By sticking my fingertips multiple times daily with a device that looked and worked like a mini-guillotine, I was able to start adjusting my insulin doses and timing of meals for the first time ever—whereas before I had to eat to feed my insulin, which had always been the same doses given at the same times. I also found out that blood glucose levels are not that easy to manage, even when you do everything the same two days in a row.

Since then, I have always appreciated being able to find out what my blood glucose is, though, especially after only having urine testing for so many years. Back in the 1990s, my insurance would only cover 4 glucose checks per day, which is woefully inadequate for most people with type 1 diabetes. I remember fighting to get them to cover 8 when I was pregnant the first time but, thankfully, now I can get almost unlimited strips for not much copay.

Back in the early 2000s, I actually did a research study on the first CGM that was approved, a non-invasive monitor called the GlucoWatch. The fact that you have probably never heard of it tells you all you need to know about how well it worked (hint: it didn’t most of the time). The device was worn on your wrist like a watch, pulled fluid out of your skin, and tested it for glucose—and left angry red marks on my skin wherever I wore it. It also shut off whenever I sweated under it, even a little bit, which happened all the time whether I exercised indoors or outdoors or just sat outdoors when it was the least bit warm.

When the first version of the Dexcom CGM came out, I tried that as well, but it was so frustrating that I gave up using it after 3 weeks and put it in the back of my closet. Half the sensors I could never get to calibrate, and the rest either died early or were horribly inaccurate. It also had a probe under the skin that did the monitoring, so it was considered an invasive device. Since then I also tried the Dexcom G5 several times, the Freestyle Libre 2, and the Dexcom G6 devices.

In short, I have loved and hated every CGM device I have ever tried. What follows is a compilation that explains why my relationship with them is so complicated.

What I love about CGM:

• Getting a glucose reading every five minutes
• Being able to see patterns and trends of my glucose levels
• Being able to check my glucose on my CGM at night without having to wake up fully
• Being able to read my glucose levels in the dark on my phone
• Not having to stick my fingers (although I really don’t mind sticking them that much)

What I hate about CGM:

• Getting a glucose reading every five minutes (especially time-delayed)
• Lag between my blood glucose and CGM glucose levels (typically 6 to 20 minutes)
• How inaccurate the glucose readings are at times, especially the first 24 hours of a new sensor (see picture) and sometimes the last few days before it hits its lifespan
• How often I end up checking my blood glucose on my meter anyway (since I don’t believe the CGM is right—and it often is not)
• Mental stress that arises from the alarms and over treating my highs (due to time lag)
• Not being able to turn off all the alarms (low alarms on a Dexcom are non-negotiable)
• The limited number of places to wear a sensor without it getting in the way or being in a spot that gets irritated (by clothing, lying on it, etc.)
• Compression “lows” from lying on the sensor or wearing tight clothing
• When its inaccuracies mess up my “time in range” values
• Having to carry my phone around with me everywhere I go (even to the next room) so it won’t lose its signal
• Not being able to adjust the placement of a sensor after I put it on (and find out it’s not in the best spot for myriad possible reasons)
• Having something on my body that often itches or hurts (and reminds me I have diabetes)
• Cost of using it—even with insurance, my copay is close to $100 a month
• Dexcom customer support (and waiting hours to talk with a rep)
• The fact that the Dexcom transmitters have an expiration date (I have had one expire before I could use it when taking a break) and that they only last 90 days from first use (although the upcoming G7 will have an integrated transmitter as part of each new sensor)

After years of inaccurate urine testing, above all I have come to expect and demand accuracy with glucose testing. I do realize that blood glucose meters are inaccurate at times, but more often than not, my fingerstick values match my symptoms (of lows and highs). I find this to be true less often with my CGM glucose readings, likely due to the time delay and other items mentioned.

I always experience a mental health boost whenever I take a break from my CGM (and I do this quite often). However, I will never ever give up using a blood glucose meter at this point—it does help to know what my glucose is doing in real time. For me personally, my A1C is equally as good whether I check my blood glucose with a fingerstick 10+ times a day or wear a CGM and get 288 glucose readings a day. If you want to try other options, don’t hold yourself back. Whatever approach works for you, stick with it. That’s what I am doing.

Dang Those Exercise Lows: What to Do to Avoid Them!

For many people, being afraid of having your blood glucose go too low when you’re active has long been a barrier to getting and staying regularly active. It’s a valid fear since many different factors can increase your risk for hypoglycemia (low blood glucose) associated with physical activity, including what activity you do, how long you do it, and how hard you are working out.

What usually happens when you exercise is that your blood glucose goes down, although there may be times and situations when it goes up instead, at least temporarily. What you may not know is that your blood glucose responses can vary based on when you last ate (1), the time of day you’re active, your biological sex, and how much total activity (intensity and duration) you do (2). Those are a lot of factors to figure out and balance appropriately when you have to take insulin.

The amount of insulin you have “on board” (injected, pumped, or inhaled) during activities impacts how likely you are to go low. When your insulin levels are higher, you use more blood glucose during the activity. This effect is compounded by how doses of insulin are absorbed—the insulin peaks later and lasts longer when you take more rapid-acting insulin (3). What’s more, the blood flow to your skin increases when you’re working out, which can speed up insulin absorption (from where it was injected or pumped), which makes you more likely to get low (4). You want to reduce the doses of insulin you take within two to three hours of exercising or lower your basal rates on your pump around exercise; it also may help to exercise more than three hours after you took any mealtime or correction insulin.

To avoid going low, you may need to eat more, monitor your glucose more frequently, and be more careful when you’re exercising in the heat, as that can speed up glucose use and cause you to go low and get dehydrated more easily. When you try a new or unusual activity, you’re more likely to get low until your body adapts to it (known as a “training effect”). Once you’re more trained, your body can switch to using slightly more fat and less carbohydrate (blood glucose included), which keeps your glucose levels more stable during that activity. Training is very specific, though, and this effect only works on the activity you have adapted to doing.

It is also possible to go low after you work out and not just during the activity. If you use up a lot of the glucose stored in your muscles (glycogen) while active, your body will remain more insulin sensitive for hours to days afterward, which can cause you to get low when you’re not expecting it—like during the middle of the night when it’s really inconvenient and harder to detect and treat quickly. Doing repeated interval workouts or intense resistance training can really use a lot of glycogen and raise your risk of later-onset lows (5). You will likely need to monitor more often after and possibly cut back on your insulin or eat more food (particularly carbohydrates) to prevent them.

Finally, you should know that most people with type 1 diabetes have impaired hormonal responses to going low, meaning that your body releases less of glucose-raising hormones like adrenaline and glucagon that helps your body recover from hypoglycemia. Having a prior low or exercising may make your responses to the next low (or exercise bout) even more blunted, so just be on the lookout for lows that can sneak up on you around times of activity. While it is possible to be active safely and effectively regardless, it may take more vigilance and a period of trial and error to get it right. You’ve got this!

References:

1. Yardley JE. Reassessing the evidence: prandial state dictates glycaemic responses to exercise in individuals with type 1 diabetes to a greater extent than intensity. Diabetologia. Aug 18 2022.  doi: 10.1007/s00125-022-05781-8.

2. Steineck IIK, Ranjan AG, Schmidt S, Norgaard K. Time spent in hypoglycemia is comparable when the same amount of exercise is performed 5 or 2 days weekly: a randomized crossover study in people with type 1 diabetes. BMJ Open Diabetes Res Care. 2021;9(1):e001919.

3. Nosek L, Roggen K, Heinemann L, Gottschalk C, Kaiser M, Arnolds S, et al. Insulin aspart has a shorter duration of action than human insulin over a wide dose-range. Diabetes Obes Metab. 2013;15(1):77-83.

4. Koivisto VA, Felig P. Effects of leg exercise on insulin absorption in diabetic patients. N Engl J Med. 1978;298(2):79-83.

5. Joy NG, Tate DB, Davis SN. Counterregulatory responses to hypoglycemia differ between glimepiride and glyburide in non diabetic individuals. Metabolism. 2015;64(6):729-37.

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.