Can You Benefit from Using Exercise Technologies and Wearable Devices?

wearable tech

What do you do when someone asks you to participate in physical activity on the spur of the moment, but you just took some insulin? You may be stuck trying to compensate for this activity entirely with food, but you may have some newer options that come from technology. For starters, if you wear a pump you can choose to lower your basal insulin delivery, and you can use its insulin-on-board calculator to see how much insulin you need to offset with either insulin reductions or food intake. However, just using your blood glucose meter can help you stay on top of your glucose levels, so check often during the activity. If you use a CGM (continuous glucose monitor), you can continue to monitor throughout to detect downward trends and treat yourself early enough to prevent lows (but just remember that there is a lag time). If you use the other wearable devices we will be discussing next, feedback on your heart rate, steps, or other variables can help you figure out how many extra calories you may need to take in to match your activity and prevent a drop in your blood glucose. With these newer technologies, at least you have options that you may not have had otherwise (1).

Exercise Technologies and Wearable Devices

You may benefit from exercise-related technologies that allow you to monitor your heart rate, blood pressure, steps, sedentary time, exercise intensity, calorie use, and other variables in real time. For instance, heart rate monitors are good for achieving and maintaining appropriate exercise intensity, particularly if you are a data-driven person and are motivated by such feedback. However, keep in mind that you need to use individualized target heart rates based on your health status. Any medications that you are taking that may limit your heart rate also need to be considered. Many apps can track your heart rate in real time and allow you to train more effectively.

Tracking steps and other physical activity can also be useful. Step counters can motivate you to be more active throughout the day, not just during your planned workout times. Keeping a daily log of step counts can allow you to determine correlations between your activity and blood glucose responses. Apps for tracking workout progress and analyzing glucose patterns related to different forms of exercise can supply the feedback, allowing you to make regimen adjustments

in real time to avoid glucose lows and highs. Many smartphones now also have integrated accelerometers that can give you data on all daily movement including your steps, along with your sleep patterns and other useful information. It is likely in the future that some of the issues surrounding exercise with fully closed-loop systems may be addressed with wearable devices that provide input about changes in activity and heart rate that can impact your blood glucose.

Whether you choose to partake of the latest technologies or not, it helps to keep some general principles in mind whether you are already regularly active or getting ready to be. These vary somewhat by your diabetes type, but are largely based on whether you have to manage your insulin levels during exercise because you use insulin. Read through these general recommendations as well as the precautions for any complicating health issues and keep these points in mind to get the most out of your workouts.

Reference:

1. Excerpted from Colberg, SR, Chapter 5, “Using Technology and Monitoring to Enhance Performance” in The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics, 2019

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Are Other (Nondiabetes) Medications Affecting Your Physical Activity?

Daily pillsIf you take any other medications to help lower your blood cholesterol, manage your blood pressure, or control other health problems, be aware that some of them can potentially impact your ability to be physically active. Although most drugs do not affect exercise, several common nondiabetes medications with such potential effects are statins, beta-blockers, diuretics, vasodilators, and blood thinners.

Statins

Statins are a class of medications prescribed to lower cholesterol levels or abnormal levels of blood fats to reduce your risk of having a heart attack or stroke. Brand names include Altoprev, Crestor, Lescol, Lipitor, Livalo, Mevacor, Pravachol, and Zocor. If you are someone who is unwilling or unable to change your diet and lifestyle sufficiently to lower your cholesterol enough or you have genetically high levels of cholesterol or triglycerides (another blood fat), then the benefit of statins on lowering your cardiovascular risk may exceed its risks. Given that cardiovascular disease (leading to heart attack and stroke) is the leading cause of death in adults with diabetes of any type, doctors often prescribe statins to people with perfectly normal cholesterol levels.

Although undesirable muscular effects are not that common, statins potentially can cause unexplained muscle pain and weakness with exercise, likely related to these medications compromising the ability of the muscles to generate energy. Other muscular conditions like myalgia, mild or severe myositis, and rhabdomyolysis, although relatively rare, are doubled in people with diabetes, along with an increased susceptibility to exercise-induced muscle injury. Other symptoms, such as muscle cramps during or after exercise, nocturnal cramping, and general fatigue, generally resolve when you stop taking statins. If you experience any of these symptoms, talk with your doctor about potentially switching to another statin or a different cholesterol-lowering medication.

About one-third of the athletes surveyed (of all ages) reported taking or having taken a statin. Many take the lowest possible dose of a statin as a heart disease preventative. Some reported getting side effects such as more frequent and severe leg cramps, muscle pain, and weakness, and others have complained of dizziness and foggy memories. Although people in the survey did not report any negative side effects, a few had to either stop taking statins or switch to another drug. (Examples of athletes’ use of statins and issues encountered are included in Chapter 3 in The Athlete’s Guide to Diabetes).

Beta-Blockers

Another class of medications called beta-blockers (e.g., Corgard, Inderal, Levatol, Lopressor, Tenormin, and Zebeta) are used to treat heart disease and hypertension (high blood pressure). They lower both your resting and your exercise heart rate. If you are taking one, your heart rate will not reach an age-expected value at any intensity of exercise, and you may not be able to work out as hard as you would like to. Be aware that your exercise responses may differ from normal when taking one of these drugs, that they can blunt your hormone response to hypoglycemia, and that they can increase your risk of more severe lows during activities.

Diuretics

Diuretics—or “water pills”—such as Lasix, Microzide, Enduron, and Lozol reduce the amount of water in your body and thereby lower your blood pressure. They can also lead to dehydration if you lose too much fluid. They are unlikely to affect your blood glucose, but using diuretics can cause dehydration with associated low blood pressure and dizziness during exercise.

Vasodilators

Taking a vasodilator like nitroglycerin allows more blood to flow to your heart during exercise, which can keep you from having to treat chest pain (angina) both at rest and during exercise. Be forewarned that vasodilators can also induce a drop in your blood pressure (hypotension), which can cause you to faint or feel light-headed during or after an activity.

Blood Thinners

If you have a high stroke risk, your doctor may put you on a blood thinner to keep clots from forming. However, aspirin and other blood thinners like Coumadin have the potential to make you bruise more easily or extensively in response to athletic injuries or to bleed longer before clotting if you get a cut or scrape while working out. If you take aspirin chronically to reduce your risk of stroke, you may only need a dose equivalent to a baby aspirin a day to limit these possible side effects. Luckily, none of these blood thinners usually have any direct impact on your ability to exercise.

Medications Without Exercise Effects

You may be prescribed a number of medications to treat a variety of health conditions. Luckily, many of these have no impact on your ability to exercise. For example, if you take an angiotensin-converting enzyme (ACE) inhibitor (e.g., Capoten, Accupril, Vasotec, Lotensin, or Zestril) or angiotensin II–receptor blocker (such as Cozaar, Benicar, or Avapro) to reduce your blood pressure or protect your kidneys from possible damage, you should not expect it to have any impact on your being physically active. In fact, certain ACE inhibitors may lower your risk of a heart attack during exercise if you have heart disease. Other medications that treat heart disease and high blood pressure (calcium-channel blockers like Procardia, Sular, Cardene, Cardizem, and Norvasc), depression (such as Wellbutrin and Prozac), or chronic pain (Celebrex) also have no known effect on exercise.

Aiming for an Ideal Exercise Blood Glucose

BG meterThere is no official ideal blood glucose range to start with and maintain during physical activity, but we do know that being too low negatively impacts performance, as does being too high. As for what blood glucose target or range most athletes aim for, it depends on a number of factors, including the type, intensity, and duration of their activity. A consensus statement about exercise and type 1 diabetes published in The Lancet in 2017 suggested that a reasonable target for most people doing aerobic exercise lasting up to an hour is 126 to 180 mg/dL (7.0 to 10.0 mmol/L), only aiming higher for added protection against lows in some situations (1).

For anaerobic (power) exercise or high-intensity interval training session, you may want to start with your glucose lower—around 90 to 126 mg/dL (5.0 to 7.0 mmol/L) simply because the intensity of the activity may cause your blood glucose to stay more stable, fall less than during aerobic workouts, or possibly even rise slightly (1).

An ideal or optimal blood glucose target during most physical activities may be in the range of 108 to 144 mg/dL (6.0 to 8.0 mmol/L).

Most of the athletes surveyed for The Athlete’s Guide to Diabetes (2019) said the range of 80 to 180 mg/dL (4.5 to 10.0 mmol/L) was their stated target during exercise. Only a few of them aim for lower or higher than that range, although most admittedly have a narrower target.

Canadian Scott L. from British Columbia agrees with recommended ranges for performance reasons, saying, “My aim is to be 6.0 to 8.0 mmol/L [108 to 144 mg/dL]. I feel the strongest at 6.0 mmol/L [108 mg/dL], but it gives me less opportunity to catch lows. Above 10.0 mmol/L [180 mg/dL], I start to feel a little sluggish—and above 15.0 mmol/L [270 mg/dL] very sluggish!”

But the blood glucose target depends on the activity and other factors. Just to give you a few examples, Chris C., a resident of New Jersey, tries to keep her blood glucose as close to 100 mg/dL (5.6 mmol/L) as she can, saying, “With high-intensity interval training my glucose will jump here and there throughout the workout with the intensity of the exercises. As soon as I am done, though, my glucose usually starts to drop.”

New York resident Riva G. uses a similar range of 80 to 150 mg/dL (4.5 to 8.3 mmol/L) for all her activities, but she likes to start on the higher end for walking. Jason O. of Ireland also varies his target based on his activity: 126 to 180 mg/dL (7.0 to 10.0 mmol/L) for cycling, just to make sure he has some leeway if he needs to make a big effort, and a tighter range of 90 to 144 mg/dL (5.0 to 8.0 mmol/L) for walking. For surfing, he aims for 5.5 to 9.0 mmol/L (100 to 162 mg/dL) in the water but uses a different target range of 4.5 to 7.5 mmol/L (80 to 135 mg/dL) for all other sports. Likewise, Ginger V. from Vermont sets the lower end of her range at 80 mg/dL (4.5 mmol/L) for all her activities, but she varies the higher end depending on whether she is doing fasted (120 mg/dL [6.7 mmol/L]) or nonfasted (150 mg/dL [8.3 mmol/L]) exercise.

The key is to find out what works best for you and maintain your blood glucose in that range during activities. Keep in mind that your glucose target may vary with the type of activity you do (mode, intensity, duration, etc.), exercise timing, insulin (or other medication) regimen, recent or concurrent food intake, environmental conditions, and multiple other factors. It’s not usually a one-size-fits-all solution.

References:

  1. Excerpted from Colberg, SR, Chapter 5, “Using Technology and Monitoring to Enhance Performance,” in The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics, 2019.

Insulin Pump Use and Exercise Strategies

imd_insulin_pump_en

Whether you have type 1 or type 2 diabetes, if you use insulin, you may choose to use a specialized insulin pump for both your basal and bolus insulin delivery (1). Pumps have a small catheter placed under your skin and are programmed to cover your basal insulin needs by delivering small doses of fast-acting insulin to mimic normal insulin release by the pancreas. Insulin pumps are programmed to deliver small, basal doses of fast-acting insulin to replicate quasi-normal insulin release by the pancreas throughout the day. These pumps are not ideal for everyone, and the choice to use one should be an individual one.

The goal of insulin pump therapy is to provide insulin just like your body would—that is, in small doses all day long, with bigger doses after meals. Although this physiological pattern can be closely mimicked using injection regimens (e.g., Levemir for basal and Apidra boluses), insulin pumps make delivery easier and offer more flexibility by allowing you to have different basal rates of insulin delivery during the day or use temporary basal settings (such as during and after exercise). Pump users have the luxury of suspending the pump or immediately reducing basal delivery of insulin for activities, which you cannot do as easily without planning ahead if you use injections.

Although the number of insulin pump companies has dwindled recently, a number of pumps with various features are still available. Although you still have to be smarter than your pump, these “smart pump” features have helped take a lot of the guesswork out of it. Most pumps have options for small basal increments (0.05 unit per hour or less), temporary basal rates, insulin-on-board calculators, menu-driven programming, and various bolus patterns. Normal boluses, for instance, give the insulin dose all at once, but extended ones allow a dose to be given over a longer period to avoid peaks and valleys in coverage for foods that are more slowly absorbed; combination boluses combine these two strategies for optimal coverage of foods like pizza. Some are waterproof at shallow depths. The race is on to create the best combination of insulin pump therapy and continuous glucose monitoring (CGM) with algorithm-driven control systems. These “closed-loop” systems integrate features and make decisions for you, although exercise remains a sizeable management hurdle to overcome.

Insulin Pump Exercise Strategies

Insulin pumps give users the opportunity to reduce basal insulin levels and/or bolus doses in desired amounts and for different durations. As a result, pump use may reduce your exercise-induced hypoglycemia risk compared to multiple daily injections. Some strategies using pump features may be helpful, based on the purpose and timing of insulin dosing (1).

Altered Bolus Doses Before Exercise: You can adjust your meal and correction doses of insulin with a high degree of accuracy to accommodate for exercise. Calculate boluses as usual (entering the actual carbohydrates and blood glucose) and then adjust them using a percentage. For postmeal activity (i.e., when bolus insulin is still peaking, such as within 2 hours after eating), reduce your meal bolus by 25, 33, or 50 percent, depending on your upcoming activity.

Lower Basal Rates During Exercise: Reducing your pump’s basal rate before, during, or after exercise by programming a temporary basal rate can allow you to eat less to compensate and prevent lows, particularly when exercising for 2 hours or more. If you can plan ahead, try reducing your basal rate somewhat starting 1 to 2 hours before exercise to make sure your insulin levels are lower when you begin. Try reducing it by 50 percent, although you may need to lower it by 80 percent for prolonged exercise.

Lower Basal Rates After Exercise: Lowering your basal insulin for a time after exercise can also keep you from getting low later when your muscle glycogen is being restored. How much you will need to reduce it will vary by person and by situation. A common starting point is to reduce your basal rate by 25 percent for 6 to 8 hours afterward if you anticipate possibly getting low later.

Alternate Basal Insulin Profiles: You can use altered delivery patterns if you are going to be doing a full-day activity, such as during summer camp, or while engaging in intense sports conditioning, or when completing major projects around your home. Pumps allow you to switch to a basal pattern that is entirely different from your usual one, allowing for significant delivery rates during peak activity and more modest reductions when you are resting afterward. If you have a pump that allows you to alter bolus calculation formulas along with basal settings (insulin delivery profiles), such as the Tandem pump, you can also use a lesser hyperglycemia correction factor, decrease your insulin-to-carbohydrate ratios, and raise your target glucose during times when you will be more insulin sensitive.

Challenges to and Solutions for Pump Use During Exercise

Insulin pump use does present its own set of challenges related to physical activity and sports. For instance, some athletes have issues with getting infusion sets to stay in place during certain activities or with excessive sweating. Others have complained that the pump or tubing simply gets in the way during exercise, and they may prefer to remove the pump entirely while active. Given that pumps deliver rapid-acting insulins only, removal of the pump for an excessive length of time (longer than 1 hour) can result in severe hyperglycemia and ketone formation, potentially leading to diabetic ketoacidosis (DKA). Exposing your pump to water and extreme weather conditions can also threaten its integrity and the insulin in it.

Reference:

  1. Excerpted from Colberg, SR, Chapter 3, “Ups and Downs of Insulin and Other Medications,” in The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics, 2019.

Brain Hormones and Relaxation Lower Mental and Physical Stress

Overweight woman stretchingAt each dawn of a new year, many people make resolutions to be more physically active—only to fail in changing their lifestyle habits in a sustained manner. Don’t be one of the many who start exercising only to stop again a few months later. Read more about why daily release of feel-good brain hormones is so important and why you should learn how to relax more as well.

Go for Daily Exercise Release of Endorphins and Other Brain Hormones

One of the most publicized mental benefits of exercise resulting from a bodily change is the release of brain hormones. The primary hormones released are called endorphins, of which there are 40 types. Basically, they are stress hormones with receptors throughout your brain and body that calm you and relieve muscle pain during intense exercise. In the brain, they contribute to your feeling of well-being or “runner’s high” that usually arises during exercise, giving you a second wind. Exercise positively influences the same brain hormones (that is, endorphins, serotonin, dopamine, and norepinephrine) as antidepressant medications, but exercise is likely even more effective than drugs for treating depression. Each workout actually boosts your mood, at least for a little while. Some people are positively addicted to this release of endorphins and need to get their daily dose. Endorphins also likely improve your body’s insulin action, thereby reversing or decreasing insulin resistance, which is why moderate aerobic training works so well for lowering it (1).

You also release dopamine in your brain during exercise, which is a key player in getting you to adopt an active lifestyle. When you release dopamine, it activates the pleasure centers in your brain, and you end up associating activity with an elevated sense of delight. That makes your brain recall pleasant feelings associated with training, and then you will be more likely to continue doing that activity to get your boost of feel-good hormones. Serotonin release, which physical activity causes, is associated with short-term improvements in your mood as well. As a bonus, you get the release of two brain endocannabinoids, which are brain neurotransmitters that dull pain. Exercise to get a maximal release of endorphins and other feel-good brain hormones on a daily basis. As a side benefit, you will feel less depressed and anxious and enjoy a greatly improved mood and better physical health.

Practice Relaxation as Well

Although each workout you do causes some physical damage to your muscles, you ultimately end up stronger, faster, and better, and your body responds by releasing fewer stress hormones (ones like cortisol, not brain endorphins) during subsequent workouts. Similarly, when you practice using relaxation techniques to control your mental stress levels, your mind learns to reduce your body’s sympathetic nervous stimulation as well. The more consistently you practice relaxation, the easier it is to avoid eliciting a strong stress response when “life happens” the next time (1).

During recovery, your parasympathetic nervous system keeps your heart rate low and digestion high, so it is no wonder that a warm shower, a big meal, and a long nap after a workout make you feel more relaxed. You are in an anabolic (building and repairing) state then, and your glycogen is being restored while your muscles are being repaired and strengthened. For best results, balance exercise with adequate rest and recovery from workouts as well.

Sport psychologists recommend relaxation to enhance performance in athletic events and even speed up healing from injuries. Relaxation techniques can help you control the stress of competition as well as the stress coming from other avenues of your life. One method to relax is to sit quietly and focus your mind. But you can even use relaxation techniques while exercising. For example, punch the air with your fists to release your anger or anxiety and consciously relax the tense muscles in your body. Use your imagination to visualize more blood flowing to all the parts of your body that need it (like your heart, muscles, hands, and feet). You may be able to enhance the blood flow to your feet simply by visualizing it, verifying that a strong mind-body connection really exists. Also, take deep and steady breaths and release them slowly, particularly during your warm-up and cool-down periods when you are not working out as hard. Whenever you start to feel winded during a workout, take deeper breaths to bring more oxygen into your lungs and body.

In summary, daily release of endorphins, dopamine, serotonin, and other mood-enhancing brain hormones and neurotransmitters through activity simultaneously better manages your blood glucose and improves your mental outlook. Learning how to use relaxation techniques can benefit you physically and mentally as well.

References:

  1. Excerpted from Colberg, SR, Chapter 6, “Thinking and Acting Like an Athlete,” in The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics, 2019.

Updated Federal Physical Activity Guidelines: Do They Apply to People with Diabetes?

shutterstock overweight exercise pixIn mid-November 2018, the U.S. Department of Health and Human Services finally released new physical activity guidelines (as a 2nd edition) to update their previous set from a decade before (1,2). Various activity guidelines for adults with diabetes have been updated several times in the interim, including a 2010 position statement on exercising with type 2 diabetes (3) published jointly by the American College of Sports Medicine and the American Diabetes Association; a 2016 ADA position statement on exercise and physical activity for all types of diabetes (4); and a consensus statement on being active with type 1 diabetes published in The Lancet in 2017 (5).

In those three sets of recommendations specific to diabetes, it was clear that everyone with diabetes can benefit from being more regularly active. Adults with diabetes should undertake a variety of activities, including aerobic, resistance, flexibility, and balance training (the last one particularly for adults over 40 or anyone with neuropathy), as well as stay more active on a daily basis just doing lifestyle activities or sitting less for better blood glucose management and weight control. The activity recommendations for adults and youth with diabetes have essentially been the same for everyone else of a similar age without diabetes.

So, what do the new federal guidelines add to the mix, if anything? Based on a review of the current research, the biggest change from the previous set of guidelines is likely that you don’t need to be active for a minimum of 10 minutes at a time for it to be beneficial to fitness and well-being. Given that many studies in the past decade have shown that breaking up sedentary behavior with short (3-minute) breaks can alter metabolism for the better, these recommendations are not surprising. They also recommend that people should sit less overall, again not a shocking guideline at this point. Studies done with people with diabetes have reached the same conclusions, so these updates certainly apply to everyone.

Another change in the federal guidelines applies to the weekend warriors: they now state that adults can derive similar health benefits if they perform all their weekly recommended physical activity in a single day or two rather than over the course of multiple days. However, whether this guideline applies as directly to people with diabetes is questionable. Past guidelines (3,4,5) have recommended that adults with diabetes not go more than two days without doing some physical activity, and many have recommended doing daily or near daily exercise for better blood glucose management. Given that the enhancing effects of your last bout of physical activity on insulin sensitivity may only last 2 to 72 hours, it seems unlikely that people with diabetes will gain all the same benefits by being a weekend warrior only—at least not when it comes to blood glucose management through reduced insulin resistance. For now, the recommendations for people with diabetes to do some type of exercise at least every other day will likely remain in place for that reason.

Finally, the new guidelines expanded out recommendations for all adults to get 150 minutes of moderate aerobic activity or 75 minutes of intense activity (or a combination thereof) each week to include up to double that amount—300 minutes moderate or 150 minutes intense aerobic training—and beyond for additional benefits. As if the bar weren’t set high enough already, you now have to find even more time to be active to gain optimal health benefits. While we already knew this was true, apparently the federal government also now recognizes how important it is for all of us to be the anti-couch potato and get as much as activity as possible to optimize our collective health! Luckily, the guidelines for doing resistance training at least two days a week are still unchanged, although we all know that doing three nonconsecutive resistance workouts a week is a preferable goal to maximize muscle gains and prevent losses of muscle (where we store carbohydrates) from aging and disuse.

In summary, these new federal physical activity guidelines really did not change what we should be doing already: getting at least 75 to 150 minutes of aerobic exercise weekly depending on its intensity (but closer to double that amount for optimal health), doing resistance training at least twice a week (but preferably three), stretching regularly, working on our balance ability if we’re older, moving more, sitting less, getting up more often, and taking the stairs instead of the elevator. So, go get active!

References:

  1. Physical Activity Guidelines for Americans, 2nd Edition, 2018. Accessed at https://health.gov/paguidelines/second-edition/.
  2. Executive Summary: Physical Activity Guidelines for Americans, 2nd Edition, 2018. Accessed at https://health.gov/paguidelines/second-edition/pdf/PAG_ExecutiveSummary.pdf.
  3. Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer B, Rubin RR, Chasan-Taber L, Albright AL, and Braun B. Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: Joint position statement. Diabetes Care, 33(12): e147–e167, 2010.
  4. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, and Tate DF. Physical activity/exercise and diabetes: A position statement of the American Diabetes Association. Diabetes Care, 39(11); 2065–2079, 2016.
  5. Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon RJ, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Millán IS, Heise T, Peters AL, Petz A, and Laffel LM. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinology, 5:377–390, 2017.

How Diets Impact Performance (in Active People with Diabetes)

French friesMany insulin users have chosen to go “low-carb” to better manage diabetes, which may or may not impact how well they perform in athletic events. How do many athletes with diabetes who swear by extreme low-carb diets that are either high in fat (like a keto diet) or higher protein (e.g., Dr. Bernstein) perform? How do their dietary choices impact both their blood glucose management and their ability to be active?

Although I personally choose to follow a more balanced diet with a moderate intake of lower-GI carbohydrates (making up less than 40 percent of my total calories), it’s mostly because I prefer plant-based foods. As a semi-vegetarian (choosing to not eat mammals), I don’t particularly like poultry, fish, and seafood that much either but eat some because it makes managing my blood glucose easier. I avoid most bread and white flour products and strictly limit how much rice, white potatoes, highly processed carb foods, and other rapidly-absorbed, high-GI carbohydrates I eat. Natural, plant-based fiber is a staple in my diet. I also exercise daily doing a variety of activities and experience very few lows when active. I don’t actively eat low carb, but I am carb-conscious and careful with my intake.

Here’s what some other active individuals with diabetes say about their diets and performance (excerpted from The Athlete’s Guide to Diabetes, Feb. 2019):

”I eat mostly low carb, but find that I often need to eat more carbs after sports in order to prevent overnight lows. I try to eat 30 percent of my daily calories from carbs, 30 percent protein and 40 percent fat each day.” — Molly M. (Canada)

“I stick to a low-carb diet. I eat a lot of meats, salads, eggs, and nuts. I avoid bread, pasta, processed food, and any type of sugar unless my blood glucose is low. I found that a low-carb diet makes it way easier to control my blood glucose throughout the day, especially during exercise. The more Humalog I use, generally the more tired I feel, and I also gain weight much easier and faster.” — Aaron G. (Minnesota)

“I normally eat a plant-based (vegetarian) nutritional lifestyle. I almost always work out fasted in the morning as I’ve discovered this is how I feel best and how I can maintain the best control over my blood glucose. I also practice intermittent fasting, with my first meal each day generally at about 11:00 a.m. and my last food intake around 8:00 p.m. My carb intake varies daily, and I don’t particularly aim to eat low carb as I eat a lot of fruit, sweet and regular potatoes, and beans. I eat eggs almost every day and rarely eat any kind of dairy product.” — Daniele H. (Pennsylvania)

“I eat reasonably low carb most of the time, though I do “carb up” for race days and tests sometimes (for performance reasons).” — Jennie B. (United Kingdom)

“I have been following a low-carb, high-fat diet for a couple of years. It makes it easier to keep blood glucose levels stable and keeps me full so less tempted to snack between meals. Though I don’t eat low enough carb to stay in ketosis. I eat 40 to 60 grams of carbohydrate per day.” — Andrea L. (France)

“I follow the metabolic efficiency diet. I eat about 125 to 150 grams of carbs per day with a diet focused on low glycemic carbs, fiber, healthy fats, and proteins. I avoid white flour and high glycemic foods.” — Conor S. (Pennsylvania)

“I stick to low carb unless in an environment of heavy training (marathon training). Consuming periodic glucose during endurance exercise and events can optimize my performance. I eat no fast food and a healthful diet full of greens and fish.” — Bill K. (Pennsylvania)

“Per Dr. Bernstein’s protocols, I eat low carb, moderate protein. I typically exercise in the morning and do not have active bolus insulin on board. I will eat small portions of dried fruit to bring my blood glucose up to 120 if it’s below that when I start. If I am going to do a race that will last more than 90 minutes, I will use UCAN 60 minutes before the race for slow acting carbohydrate during the event.” — Jason S. (New York) 

“I eat low-carbohydrate, high-protein, high-healthful fat meals. I recently cycled from Perth to Sydney, solo and unsupported in a time frame of 20 days, following low carb. As a fat-adapted athlete, this also disproved any theories that such exercise must be performed consuming a high-carbohydrate diet.” — Neil M. (Australia)

“I am, for the most part, on a Paleo diet. My carb intake is ~20 to 40 grams a day. By not needing to cover a large card intake, my boluses are less, thus I am not partaking in an odyssey of hours of either being hugely high or low due to a miscalculation. The law of small numbers is the key here.” — Jay H. (Wisconsin)

“Changing my diet to no starchy carbs has been magic. I dropped Lantus from more than 30 units down to 18 per day since dropping ALL starchy carbs. I eat no breads, pasta, cereal…The carbs I consume include veggies only. Most of my workouts now require no insulin management, and I seldom get low.” — Tom S. (Texas)

“I am carb-conscious. I do not eat low carb but make smart carb decisions. I aim to eat unprocessed, homemade food as much as possible. I love cooking in the backcountry and enjoy finding recipes that are dehydrated, lightweight, nutritious, and carb-rich for trekking days, and fueling.” — Jen H. (Canada)

“I was most helped by switching my diet and way of handling my diabetes to the Dr. Richard K. Bernstein method. I spent 47 and a half years stuffing glucose in my face all day long when I was skiing, hiking, or swimming just to keep my blood sugar above 100 (5.6) and then having it fly up to the 200 to 300s later. Now that I’m eating very low carb, this problem is greatly minimized. Eating this way has significantly flattened my blood glucose graph and prevented the precipitous, scary lows of the past. I’m so thankful to have found this way of handling type 1 diabetes.” — Mary Alice (California)

“I tend to eat low on the glycemic index and very little gluten. I substitute bean noodles for wheat, and quinoa is a staple. I eat a lot of slow-cooked meals with beans and vegetables. Breakfast is usually full-fat Greek yogurt. During trail races, I eat hard-boiled eggs and potatoes, items that provide nutrition, but don’t require a bolus. I don’t drink sports drinks or anything with sugars that need insulin. For low correction, I eat dried fruit which I find is kinder on the stomach than simple sugars in sports drinks. I don’t eat Gu or other sports gels. The less insulin in my system around exercise the better. This is not to be mistaken for low-carb or low-calorie diet; it’s just low-GI.” — Blair R. (California)