Sure, You May Lose Weight, But Will Going Low-Carb Impact Your Performance?

With the new year upon us and resolutions made, weight loss may be on your mind and with it low-carb eating as one potential way to cut back on calories. Before you decide how to go about losing weight, though, you may want to consider how cutting back on your carbohydrate intake may affect your ability to be physically active.

Although their long-term benefits on managing blood glucose levels are mixed (1), the popularity of low-carbohydrate diets has continued to rise among people with diabetes, especially those with type 1 diabetes (T1D). The exact carbohydrate intake that is “low” is not well defined, but under 130 grams (g) per day or <26% total energy intake or less than 3 g per kilogram of body weight daily is considered low by most (2, 3). Research on the glycemic impact of low-carbohydrate diets has largely involved highly motivated individuals with T1D engaging in frequent glucose monitoring and insulin adjustments to achieve tight glucose targets.

Adherence to such restricted diets is challenging, and carbohydrate-containing foods like whole grains, fruit, and dairy provide essential nutrients that many low-carbohydrate diets lack (3). The potential for diabetic ketoacidosis, hypoglycemia, altered blood lipids, and depleted glycogen (carbohydrate stores) when following very low-carbohydrate diets remains a concern (4); moreover, adults with T1D consuming less than 50 g per day may not react well to rescue glucagon used to treat hypoglycemia, likely due to a reduced liver glycogen (5).

As for exercise performance, your body’s preferential use of carbohydrate as a metabolic fuel during moderate and intense activities may make it difficult to perform optimally when you severely restrict your carbohydrate intake, especially prior to, during, and after exercise training and events (6). Prolonged endurance activities are limited by carbohydrates being available, and low-carbohydrate diets have the potential to limit muscle glycogen stores (7), particularly without a prior period of adaptation (such as a few weeks).

While your blood glucose use typically increases during most activities, the amount that is available when levels are in a normal range is very limited (only ~4 to 6 g of total glucose, depending on your size). While blood glucose production increases during activity from hepatic glycogen breakdown (glycogenolysis) or de novo (new) glucose formation (gluconeogenesis), the majority of carbohydrates muscles use comes from glucose stored as glycogen (8).

In the body, carbohydrates stores are limited in the skeletal muscles (typically 300 to 400 g) and the liver (more in the range of 80 to 100 g). Given the importance of carbohydrate availability during many sports and activities, pre-exercise levels of muscle glycogen in particular frequently determine how well you perform (9). Moreover, replacement of these stores during recovery depends on the availability of blood glucose, which can come directly from carbohydrates you consume or from new glucose made by your liver from metabolic precursors like lactate, pyruvate, alanine, and glycerol (10).

In addition, in people with T1D, effective glycogen repletion requires adequate food intake, blood glucose management, and insulin availability during recovery (11, 12). Elevated blood glucose can lead to lower liver glycogen storage (13). If you start exercising with low muscle and/or liver glycogen stores, you will likely need to take in carbohydrates during extended activities and may not perform as well. If you engage in activities that rely largely on muscle glycogen for fuel, such as many power–endurance and power sports, a low-carbohydrate diet may be detrimental to performance by limiting your ability to rapidly resynthesize adequate amounts of ATP, the energy molecule used for muscle contractions.

Adapted from Colberg SR, Nutrition and exercise performance in adults with type 1 diabetes. Canadian Journal of Diabetes, 44(8):750-758, 2020 (https://doi.org/10.1016/j.jcjd.2020.05.014)

References:

  1. Turton JL, Raab R, Rooney KB. Low-carbohydrate diets for type 1 diabetes mellitus: A systematic review. PloS one. 2018;13(3):e0194987-e. doi: 10.1371/journal.pone.0194987. PubMed PMID: 29596460.
  2. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ, Westman EC, et al. Dietary carbohydrate restriction as the first approach in diabetes management: critical review and evidence base. Nutrition. 2015;31(1):1-13. doi: 10.1016/j.nut.2014.06.011. PubMed PMID: 25287761.
  3. Seckold R, Fisher E, de Bock M, King BR, Smart CE. The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes. Diabetic Medicine. 2019;36(3):326-34. doi: 10.1111/dme.13845. PubMed PMID: 30362180.
  4. Leow ZZX, Guelfi KJ, Davis EA, Jones TW, Fournier PA. The glycaemic benefits of a very-low-carbohydrate ketogenic diet in adults with Type 1 diabetes mellitus may be opposed by increased hypoglycaemia risk and dyslipidaemia. Diabetic medicine : a journal of the British Diabetic Association. 2018:10.1111/dme.13663. doi: 10.1111/dme.13663. PubMed PMID: 29737587.
  5. Ranjan A, Schmidt S, Damm-Frydenberg C, Steineck I, Clausen TR, Holst JJ, et al. Low-Carbohydrate Diet Impairs the Effect of Glucagon in the Treatment of Insulin-Induced Mild Hypoglycemia: A Randomized Crossover Study. Diabetes care. 2017;40(1):132-5. doi: 10.2337/dc16-1472. PubMed PMID: 27797928.
  6. Cermak NM, van Loon LJ. The use of carbohydrates during exercise as an ergogenic aid. Sports Med. 2013;43(11):1139-55. doi: 10.1007/s40279-013-0079-0. PubMed PMID: 23846824.
  7. Yeo WK, Carey AL, Burke L, Spriet LL, Hawley JA. Fat adaptation in well-trained athletes: effects on cell metabolism. Appl Physiol Nutr Metab. 2011;36(1):12-22. doi: 10.1139/h10-089. PubMed PMID: 21326374.
  8. Jensen TE, Richter EA. Regulation of glucose and glycogen metabolism during and after exercise. J Physiol. 2012;590(Pt 5):1069-76. doi: 10.1113/jphysiol.2011.224972. PubMed PMID: 22199166.
  9. Areta JL, Hopkins WG. Skeletal Muscle Glycogen Content at Rest and During Endurance Exercise in Humans: A Meta-Analysis. Sports Med. 2018;48(9):2091-102. doi: 10.1007/s40279-018-0941-1.
  10. Jensen J, Rustad PI, Kolnes AJ, Lai YC. The role of skeletal muscle glycogen breakdown for regulation of insulin sensitivity by exercise. Frontiers in physiology. 2011;2:112. doi: 10.3389/fphys.2011.00112. PubMed PMID: 22232606.
  11. Buehler T, Bally L, Dokumaci AS, Stettler C, Boesch C. Methodological and physiological test-retest reliability of (13) C-MRS glycogen measurements in liver and in skeletal muscle of patients with type 1 diabetes and matched healthy controls. NMR in biomedicine. 2016;29(6):796-805. doi: 10.1002/nbm.3531. PubMed PMID: 27074205.
  12. Bischof MG, Bernroider E, Krssak M, Krebs M, Stingl H, Nowotny P, et al. Hepatic glycogen metabolism in type 1 diabetes after long-term near normoglycemia. Diabetes. 2002;51(1):49-54. doi: 10.2337/diabetes.51.1.49. PubMed PMID: 11756322.
  13. Hwang JH, Perseghin G, Rothman DL, Cline GW, Magnusson I, Petersen KF, et al. Impaired net hepatic glycogen synthesis in insulin-dependent diabetic subjects during mixed meal ingestion. A 13C nuclear magnetic resonance spectroscopy study. J Clin Invest. 1995;95(2):783-7. doi: 10.1172/JCI117727. PubMed PMID: 7860761.

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What You Eat and Drink Affects Your Exercise Performance

How well you perform (physically) when you exercise is impacted in a number of ways by the intake of macronutrients—that is, carbohydrate, fat, and protein—whether you have diabetes or not (1, 2). Performance is directly affected by your calorie intake both during an activity and when you are recovering from it. Recovery, by definition, includes the entire time between the end of your last workout or competition and the start of the next one. In many cases, you may need to modify what you eat and drink for different types of training and competition, and periodized (that is, changing over periods of timing for training vs. competition) guidelines can lead you to the appropriate type, amount, and timing of intake of macronutrients and fluids to help you perform optimally (2).

All active people can experience a relative energy imbalance resulting from a mismatch between how many calories they’re consuming and how many they’re using during exercise and recovery. Many nutritional strategies for training and competition may involve pre-event, during-event, and between-event eating to address how to adequately replace calories and fluids. In addition to these and other factors (including muscle and liver glycogen storage and use, hydration, and micronutrient and electrolyte status), individuals with diabetes are additionally impacted by their blood glucose management (see figure).

Exercise carbohydrate requirements depend on an individual’s training status for a given event, as well as on environmental and other factors. When highly trained athletes compete in higher-intensity endurance events lasting up to 3 hours, carbohydrate remains the predominant fuel for the working muscles and its availability becomes rate limiting for performance, not fat availability (3). Anecdotally, according to active insulin users with diabetes, maintenance of their blood glucose levels at more normal levels improves exercise performance (4,5). You may need to adjust both your carbohydrate/food intake and insulin doses to prevent hypoglycemia or hyperglycemia during physical activity (6, 7). Supplementing with carbohydrate remains a proven strategy to increase endurance and intermittent sports performance in individuals without diabetes (8); carbohydrate intake has the greatest impact during activities that would lead to fatigue and/or low blood glucose (9), likely by providing an alternate fuel and sparing glycogen (stored glucose) in select muscle fibers (10). Glucose uptake into active muscles primarily occurs through a contraction-mediated, insulin-independent mechanism during activity, making its use as a fuel possible even if someone is insulin resistant (11).

Although protein use as a fuel during most activities is admittedly minimal, adequate daily intake of protein, mostly during recovery, may also impact overall performance. For most regularly training individuals, daily protein requirements are roughly 1.1 to 1.5 g of protein per kg (2.2 pounds) of body weight (roughly 15% to 20% of total calories) (12). Although aging by itself increases the need for quality protein, its intake is particularly critical in strength training athletes and individuals engaging in long duration aerobic training. If you fail to take in enough daily calories, your protein needs may be increased by exercise, whether or not you have diabetes.

Adapted from Colberg SR, Nutrition and exercise performance in adults with type 1 diabetes. Canadian Journal of Diabetes, 2020 Jun 2:S1499-2671(20)30152-0 (https://doi.org/10.1016/j.jcjd.2020.05.014)

References:

  1. Burke LM, Ross ML, Garvican-Lewis LA, Welvaert M, Heikura IA, Forbes SG, et al. Low carbohydrate, high fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers. J Physiol. 2017;595(9):2785-807. doi: 10.1113/JP273230.
  2. Burke LM, Castell LM, Casa DJ, Close GL, Costa RJS, Desbrow B, et al. International Association of Athletics Federations Consensus Statement 2019: Nutrition for Athletics. Int J Sport Nutr Exerc Metab. 2019;29(2):73-84. doi: 10.1123/ijsnem.2019-0065.
  3. Hawley JA, Leckey JJ. Carbohydrate dependence during prolonged, intense endurance exercise. Sports Med. 2015;45 Suppl 1:S5-12. doi: 10.1007/s40279-015-0400-1.
  4. Colberg S. The Athlete’s Guide to Diabetes: Expert Advice for 165 Sports and Activities. Champaign, IL: Human Kinetics; 2020. 382 p.
  5. Bally L, Laimer M, Stettler C. Exercise-associated glucose metabolism in individuals with type 1 diabetes mellitus. Curr Opin Clin Nutr Metab Care. 2015;18(4):428-33.  doi: 10.1097/mco.0000000000000185.
  6. Campbell MD, Walker M, Bracken RM, Turner D, Stevenson EJ, Gonzalez JT, et al. Insulin therapy and dietary adjustments to normalize glycemia and prevent nocturnal hypoglycemia after evening exercise in type 1 diabetes: a randomized controlled trial. BMJ Open Diabetes Res Care. 2015;3(1):e000085. doi: 10.1136/bmjdrc-2015-000085.
  7. Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, et al. Exercise management in type 1 diabetes: a consensus statement. Lancet Diabetes Endocrinol. 2017;5(5):377-90. doi: 10.1016/S2213-8587(17)30014-1.
  8. Vandenbogaerde TJ, Hopkins WG. Effects of acute carbohydrate supplementation on endurance performance: a meta-analysis. Sports Med. 2011;41(9):773-92. doi: 10.2165/11590520-000000000-00000.
  9. Baker LB, Rollo I, Stein KW, Jeukendrup AE. Acute effects of carbohydrate supplementation on intermittent sports performance. Nutrients. 2015;7(7):5733-63. doi: 10.3390/nu7075249.
  10. De Bock K, Derave W, Ramaekers M, Richter EA, Hespel P. Fiber type-specific muscle glycogen sparing due to carbohydrate intake before and during exercise. J Appl Physiol (1985). 2007;102(1):183-8. doi: 10.1152/japplphysiol.00799.2006.
  11. Richter EA, Hargreaves M. Exercise, GLUT4, and skeletal muscle glucose uptake. Physiol Rev. 2013;93(3):993-1017. doi: 10.1152/physrev.00038.2012.
  12. American Dietetic A, Dietitians of C, American College of Sports M, Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc. 2009;41(3):709-31. doi: 10.1249/MSS.0b013e31890eb86.

Be Physically Active to Boost Your Immune Response

In these challenging times, if we only could get a medication that would boost our immune system and response to viruses, lower all stress associated with being in a pandemic, and treat most of the pre-existing health conditions that are associated with a higher risk of dying from COVID-19, we would all be lined up for it! Guess what? We already have something that does all these things already—and that is physical activity.

Let’s consider its impact on how well your immune system works. While physical activity can boost your immune function, here’s what else we know about the immune system and all the lifestyles factors we can manage:

Exercise: A single workout may temporarily suppress your immune system, but chronic training (assuming it is not excessive) boosts immunity to the common cold, other viruses, and a whole host of pathogens (1). Being regularly active generally makes you less likely to get sick.

Stress: Any type of stressor, be it physical or mental, can weaken your immune system, most commonly through increases in levels of the hormone cortisol and other factors (2). Exercise overtraining raises cortisol levels and can make you more likely to catch a cold or the flu.

Sleep: Lack of sleep—particularly deep REM sleep—and short sleep duration cause a rise in cortisol levels that can dampen immune function (3). Many people with type 2 diabetes and overweight/obesity also have sleep apnea that interferes with getting quality sleep, making them more susceptible to getting sick. Better management of all of these conditions helps.

Nutrition: Chronic malnutrition lowers the ability of the immune system to function optimally. Low levels of vitamin D (which acts as a prohormone) in the bloodstream has also been tied with lower immunity, and many people with diabetes and older adults have low vitamin D status. Getting adequate vitamins, minerals, and calories in your diet can boost your immunity.

Alcohol: While a moderate intake of alcohol may give you some health benefits, abuse of alcohol suppresses your immune system (4). “Moderate” is one drink per day for females, two for males—and there is no rollover from one day to the next if you miss one!

Smoking: Tobacco smoking increases inflammation and lowers immune function, and it may also lower your immune response to certain vaccines. Quitting smoking can help restore immune function.

We also need to discuss how our bodies react to vaccinations. All of us are facing possible vaccination for COVID-19 once a safe and effective vaccine is available. You may be, like I was previously, assuming that vaccines work the same for everyone. In reality, there is no guarantee of a universal and equally protective response, and a whole host of factors (inside your body and out) can impact how well a vaccine actually works for you (5). Not surprisingly, all of the lifestyle factors listed above can impact the strength of your immunity post-vaccination, and making improvements in any/all of them can help. But your age can also have a negative effect.

COVID-19 is unlikely to be the last threat to our collective health, so it is worth discussing why we are more vulnerable to threats to our immune system as we get older. For starters, older adults have a less robust immune response to everything, including strains of influenza, and they suffer from a more rapid waning of antibodies. Basically, our immune systems are getting less robust and effective as we age—and that potentially impacts our response to vaccines.

Generally, older adults have a lesser immunity to any virus that they have been vaccinated against, and that will likely include the current global coronavirus once a vaccine is available. However, engaging in regular aerobic training improved flu vaccine responses in a group of older adults who had been previously sedentary (6): participants who did a regular moderate-intensity physical activity like brisk walking were 30 to 100 percent more likely to have an antibody response sufficient to keep them from getting the flu. Although research on this topic remains limited, exercise is likely to help boost the immune systems in people who are currently sedentary and start being active.

Other confounding health issues may make immune responses weaker when you are exposed to a virus or vaccinated. For instance, many seniors with diabetes develop kidney disease requiring dialysis. In these individuals, many fail to have an adequate immune response when given a vaccine for hepatitis B; how well it works depends on their age, how long they have been on dialysis, their diet, and other factors (7). In children (and adults) with type 1 diabetes, certain vaccines have been shown to be less effective, particularly when they also have celiac disease and consume gluten (8).

So, what can you do? Fight back by adopting the healthiest lifestyle that you can—one that includes being regularly moderately active—and stay as healthy as you can for when the next virus comes along. Protect yourself with a daily dose of exercise!

References:

  1. Cerqueira É, Marinho DA, Neiva HP, Lourenço O. Inflammatory Effects of High and Moderate Intensity Exercise-A Systematic Review. Front Physiol. 2020 Jan 9;10:1550. doi: 10.3389/fphys.2019.01550. PMID: 31992987.
  2. McEwen BS. Central effects of stress hormones in health and disease: Understanding the protective and damaging effects of stress and stress mediators. Eur J Pharmacol. 2008 Apr 7;583(2-3):174-85. doi: 10.1016/j.ejphar.2007.11.071. PMID: 18282566.
  3. Vgontzas AN, Zoumakis M, Bixler EO, et al. Impaired nighttime sleep in healthy old versus young adults is associated with elevated plasma interleukin-6 and cortisol levels: physiologic and therapeutic implications. J Clin Endocrinol Metab. 2003 May;88(5):2087-95. doi: 10.1210/jc.2002-021176. PMID: 12727959.
  4. Rodríguez-Rabassa M, López P, Sánchez R, et al. Inflammatory Biomarkers, Microbiome, Depression, and Executive Dysfunction in Alcohol Users. Int J Environ Res Public Health. 2020 Jan 21;17(3):689. doi: 10.3390/ijerph17030689. PMID: 31973090.
  5. Zimmermann P, Curtis N. Factors That Influence the Immune Response to Vaccination. Clin Microbiol Rev. 2019 Mar 13;32(2):e00084-18. doi: 10.1128/CMR.00084-18. PMID: 30867162.
  6. Woods JA, Keylock KT, Lowder T, et al. Cardiovascular exercise training extends influenza vaccine seroprotection in sedentary older adults: the immune function intervention trial. J Am Geriatr Soc. 2009 Dec;57(12):2183-91. doi: 10.1111/j.1532-5415.2009.02563.x. PMID: 20121985.
  7. Udomkarnjananun S, Takkavatakarn K, Praditpornsilpa K, et al. Hepatitis B virus vaccine immune response and mortality in dialysis patients: a meta-analysis. J Nephrol. 2020 Apr;33(2):343-354. doi: 10.1007/s40620-019-00668-1. Epub 2019 Nov 7. PMID: 31701375.
  8. Opri R, Veneri D, Mengoli C, Zanoni G. Immune response to Hepatitis B vaccine in patients with celiac disease: A systematic review and meta-analysis. Hum Vaccin Immunother. 2015;11(12):2800-5. doi: 10.1080/21645515.2015.1069448. Epub 2015 Sep 17. PMID: 26378476.

Pumping Up With Protein: Does This Work for Exercise and Health?

Protein is never a key exercise fuel, but it’s critical for other reasons. During most exercise, protein contributes less than 5 percent of the total energy, although it may rise to 10 to 15 percent during a prolonged event like a marathon or Ironman triathlon. Taking in enough dietary protein is important because dietary protein allows your muscles to be repaired after exercise and promotes the synthesis of hormones, enzymes, and other body tissues formed from amino acids, the building blocks of protein.

You should consume at least 12 to 35 percent of your daily calories as protein. For most people this means taking in at least 60 grams of protein daily.

About half of the 20 amino acids are considered essential in your diet, meaning that you must consume them or your body will suffer from protein malnutrition, which causes the breakdown of muscles and organs. Essential amino acids are found in meats, poultry, fish, dairy, eggs, and soy products; all plant-based foods besides soy are lacking one or more essential ones, but taking in combinations of plant sources (like rice and beans) can supply what you need.

Your body can make the rest of the amino acids itself (they are the nonessential ones). But you need to have enough protein in your diet overall to synthesize body proteins after workouts, which is a critical time for increases in strength, aerobic capacity, or muscle size.

Because protein is important to overall health but isn’t a major exercise fuel, you do need to worry about consuming enough, although it doesn’t have to happen right before or during an activity. You’ll get most effective restoration of liver glycogen if you keep your blood glucose levels in tight control after exercise. Consuming a small amount of protein along with carbohydrate (in a ratio of 1:4, or one gram of protein to every four grams of carbohydrate) after an activity may help you repair your muscles and get stronger more quickly.

Typically, an ounce of chicken, cheese, or meat has about 7 grams of protein.

Taking in more protein and slightly less carbohydrate after exercise can help keep your blood glucose more stable over time because protein takes three to four hours to be fully digested, and some protein is converted into blood glucose. You can eat protein strategically to prevent later-onset hypoglycemia, which insulin users are more likely to get. Have some in your bedtime snack (along with fat and carbohydrate) to prevent nighttime lows after a day of strenuous or prolonged activity, if you use insulin.

Taking in some protein along with carbohydrate right after hard or long workouts may ­help ­your body ­replenish ­its ­glycogen ­stores ­more ­effectively. Though­ anyone ­who ­is ­getting ­older—­and ­that ­includes ­all ­of ­us—­can­ benefit from taking in enough protein, supplements are usually not the optimal way to get enough. Let me explain why.

As you get older, your body may need a more protein compared to when you were younger ­to form, maintain, ­and­ repair ­muscles­ and­ other ­body ­structures. Anyone who is doing regular exercise training also needs more protein to repair and build muscle, but you can usually get this amount (and more) when you’re eating ­a­­ balanced ­meal ­plan ­with ­adequate ­calories. To­ figure out ­how­ much ­you need, ­find ­the ­category ­that ­fits ­your ­age ­and ­training, ­and ­multiply ­your body weight­ (in pounds­ or­ kilograms)­ by­ the­ grams­ found­ in­ the­ corresponding table ­column.

TABLE           Recommended Protein Intake by Training Status and Age

Per Pound Body Weight         Per Kilogram Body Weight

Adults 19 to 50 years (inactive)          0.36 grams                              0.8 grams

Adults over 50 years (inactive)           0.5 grams                                1.1 grams

Endurance training                              0.55–0.64 grams                     1.2–1.4 grams

Strength training                                 0.68–0.77 grams                     1.5–1.7 grams

Calorie deprived (diets)                      0.73–0.82 grams                     1.6–1.8 grams

The biggest myth about amino acid supplements, and protein in general, is that you must load up on them to gain muscle. That’s just not true. The protein requirement for strength-training athletes may be about twice as high as normal, but most people in the United States already consume more than these higher amounts of protein in their daily diets.

To put it in perspective, to gain one pound of muscle mass a week (a realistic maximum), a strength-training athlete needs no more than 14 extra grams of quality protein per day. You can easily get this amount from these sources:

» About two 8-ounce glasses of milk

» 2 ounces of lean meat, chicken, fish, or cheese (which isn’t much)

» Slightly more than 2 eggs (only the whites contain protein)

Adequate intake of protein also helps to maintain lean body mass when you lose weight on a diet and can help you gain more muscle mass from exercise training.

Reference:  Excerpted from Colberg, SR, “Chapter 7: Eating Right for Exercise,” Diabetes & Keeping Fit for Dummies, Wiley, 2019.

Regaining Fitness in a Post-Pandemic World

Yes, I know we’re still dealing with a life-changing pandemic around the world and especially in most areas of the United States, but it is still worth thinking ahead to what comes next. Despite our discussion last month on non-gym fitness trends (focused around an article in Time [1]), it is more than likely that many of us have experienced a change (most often a decrease) in our daily physical activities and, subsequently, in our aerobic and muscular fitness levels.

A recent study conducted in Washington state (the state first impacted by curtailed daily activities) showed that strategies to mitigate the COVID-19 pandemic may be impacting physical activity and mental health, with those experiencing a decrease in physical activity also having higher levels of stress and anxiety (2). While a few of us may have gotten more active while working from home or having an altered daily life, the rest of us have had to curtail our activities—if not our workouts in public spaces like gyms and pools, at least our daily movement. When confined to our homes for working and learning, the lack of a daily commute to arrive at work or school by itself can remove a lot of daily steps that people would otherwise be taking, and mental stress and anxiety may be leading people to engage in other less healthy behaviors like stress eating.

Past research has demonstrated greater strength gains and blood glucose improvements from doing resistance training using harder weights or resistance than most people have access to at home, and regular participation is reinforced by supervision during training sessions and/or by social support arising from group exercise (2,3) What does that say about the future of working out at home, seldom if ever supervised and often alone? It may be hard to predict, but it is undeniable that doing any activity is better than none at all. Nonetheless, it is entirely likely that we will have lost some aerobic capability and muscular strength by the time we are able to restart our pre-pandemic activities.

So, what can we do to prepare to fully reenter the fitness world after it is finally considered safe to resume our pre-pandemic lifestyles? The best way to be ready is to stay as active as possible by doing anything you can from home or other safe venues now. That includes getting involved in virtual fitness classes, dusting off and using any exercise equipment you have at home, doing exercises using your body weight as resistance, and breaking up your sedentary time frequently, regardless of where you are working or learning.

Here are some other tips to keep in mind:

  • Find some time every day to be active, even if you only stand up during meetings instead of sitting or do easy exercises next to your desk.
  • Do more spontaneous activity, including getting up to break up sitting time for a few minutes every 20 to 30 minutes.
  • Use whatever equipment or household items you have access to in order to add a little resistance training to your day (aim for two to three days per week).
  • Use the latest technology or other tracking device to make sure you are getting in a minimum of activity every day (set daily and weekly goals for yourself).
  • Start out slowly and progress slowly over time once you can get back into doing more and harder activities as your top priority should be gaining fitness without injuring yourself.

Remember, when you’re starting out all over again, the same principles apply as when you began getting physically fit in the first place. Avoid the pitfalls that can lead to injury and demotivation, such as starting back at too high of an intensity. Hopefully, if nothing else, this pandemic will have lead people to become more creative with their workouts and help everyone find ways to fit in more activity into their daily lives, during and after we’re through this rough patch.

References:

  1. Time magazine, July 15, 2020: https://time.com/5867166/covid-19-gyms-exercise/?fbclid=IwAR1DVNQEd03PaHdwZXSKlRNhYvlMosxVYg_Gfy5weAyk89Q5NTt82DRY8og
  2. Duncan GE, Avery AR, Seto E, Tsang S. Perceived change in physical activity levels and mental health during COVID-19: Findings among adult twin pairs. PLoS One. 2020;15(8):e0237695. Published 2020 Aug 13. doi:10.1371/journal.pone.0237695
  3. Dunstan DW, Daly RM, Owen N, et al. High-intensity resistance training improves glycemic control in older patients with type 2 diabetes. Diabetes Care. 2002;25(10):1729-1736. doi:10.2337/diacare.25.10.1729
  4. Dunstan DW, Daly RM, Owen N, et al. Home-based resistance training is not sufficient to maintain improved glycemic control following supervised training in older individuals with type 2 diabetes. Diabetes Care. 2005;28(1):3-9. doi:10.2337/diacare.28.1.3
  5. Dempsey PC, Larsen RN, Sethi P, et al. Benefits for Type 2 Diabetes of Interrupting Prolonged Sitting With Brief Bouts of Light Walking or Simple Resistance Activities. Diabetes Care. 2016;39(6):964-972. doi:10.2337/dc15-2336

Working Out at Home: Is This the Wave of the Future?

The current pandemic has hit most traditional gyms and fitness centers hard, especially once more has been learned about the likely spread of the virus through respiratory droplets. There are admittedly few places with more collective heavy breathing than you’ll find in indoor workout venues!

After reading a recent article in Time on non-gym fitness trends in a COVID-19 world, I started asking others how they have been coping with transitioning to home-based workout routines. I asked, “So what’s your new favorite, home-based physical activity?” Most of the people who voluntarily answered my queries were coping quite well actually. Here are some examples:

  • Virtual fitness classes, Zumba, Pilates, Yoga and free weights on my own. I also teach virtual classes these formats.
  • Garage workouts and family bike rides
  • My total gym machine and I have made up and are a thing again. Hand weights with my favorite TV shows work well.
  • I love riding my bike ❤️
  • I have enjoyed TRX, kettlebell, and resistance band workouts.
  • Rediscovered exercise bands which I use with my home weights, coupled with daily walks. I’ve enjoyed training differently to going back to the gym. Will I go back to the gym? I think so when the old flexibility of going when I want rather than booking time in around new hours.
  • LOVE using the @Ergatta program with my indoor WaterRower rowing machine!
  • Not at home but, a very socially distant sport is Disc Golf. A nice walk in a park, but also focuses on eye hand coordination. Throwing skills can also be learned.
  • Living in a province with an awesome chief public health officer, Dr. Bonnie Henry, who has encouraged people to exercise outside, while observing physical distancing precautions.
  • Dance warm ups and indoor rowing, oh and chasing baby rabbits round the garden.
  • I’ve finally started my power walks right here in the neighborhood or on the beach. Fringe benefit: I know my way around the community now!

And my personal favorite:

  • Do beach walks count?

Yes, absolutely they do! (Just remember to social distance and wear a face covering when you can’t stay at least six feet apart from others on the beach.) Actually, all of the activities listed can work for you, as can many others. (Please feel free to access and download some of the anywhere, anytime exercises I recommend through the Resources page on Diabetes Motion Academy at https://www.dmacademy.com/resources.)

Later in the July 2020 Time article, it states, “Only 20% of Americans said they’d feel comfortable going to a gym as of July 13, according to a Morning Consult poll. Another survey, conducted by market-research firm OnePoll and commissioned by LIFEAID Beverage Co., found that 25% of Americans never plan to go back.” I have heard similar comments from family members and friends who were, up until a few months ago, consistent gym-goers, as I was myself.

What does that say about the future of working out at home versus returning to the gym once this pandemic is under control? I think that remains to be seen. However, if we can all figure out ways to be more physically active around our homes and neighborhoods without needing to shoulder the cost of joining a gym or the inconvenience of getting there, that may lead to all of us become and remain more active and improve our collective health far more than we have been able to do with gym memberships and lapsed attendance.

Gyms will still exist after this pandemic ends—at least some of them—and many people will enjoy going back to them and restarting their old workout routines. However, with the pervasive availability of the internet nowadays, the potential for use of Zoom and other virtual interactions, and additional innovative means of connecting to exercise and active communities remotely, I personally look forward to seeing what new and creative avenues this pandemic ends up leading us to in the fitness world!

Reference: Time magazine, July 15, 2020: https://time.com/5867166/covid-19-gyms-exercise/?fbclid=IwAR1DVNQEd03PaHdwZXSKlRNhYvlMosxVYg_Gfy5weAyk89Q5NTt82DRY8og

Exercising with Type 1 Diabetes: The Insulin-Food Balance Challenge

Addressing how to balance blood glucose levels during (and after) exercise with type 1 diabetes is not new. In fact, it is likely the KEY topic to address to be successful at being physically active if you take exogenous insulin and want to prevent hypoglycemia or hyperglycemia during exercise. Strategies include changing in insulin doses and/or supplementing with food, either of which can be done in myriad ways depending on the activity, timing, and more.

A recent 2020 study revisited whether it works better to supplement with carbohydrates or lower bolus (meal-time) insulin doses before exercise to prevent lows (1). Its conclusion—for this particular group of subjects doing continuous, moderate-intensity cycle ergometer exercise for ∼45 minutes—was that taking in 15 to 30 grams of carbohydrate when blood glucose levels decreased to 7.0 mmol/L (126 mg/dL) prevented hypoglycemia better. Okay, but….

My issue with these types of studies is not that they don’t prove a point—they do—but it’s that they prove a very, very narrow point. The results can only be generalized to people with the same physical fitness level, age, sex, and diet undertaking a specific type, intensity, duration, and timing of activity. Exercising with type 1 diabetes is so much broader than that. Moreover, it’s not just short-term insulin dosing or immediate carbohydrate intake that have an impact on balancing blood glucose and affecting how successful you are at being active.

Whether participating in sports or physical activity on a recreational basis or striving to be a professional or Olympic athlete, anyone who takes insulin must pay attention to his or her unique nutritional and dietary patterns, including intake of macronutrients (carbohydrate, protein, and fat), micronutrients (vitamins and minerals), fluids, and supplements like caffeine to maintain metabolic and glycemic balance (2). Athletic performance aside, nutritional recommendations may also differ on an individual basis relative to exercise, glycemic management, and body weight goals. Balancing all these dietary factors can be challenging for individuals with type 1 diabetes, and many related aspects have yet to be fully researched in this population.

Carbohydrates undeniably have the most immediate impact on blood glucose and must be matched with adequate insulin doses to manage blood glucose peaks after eating (3), but protein and fat intake can impact insulin needs as well (4). When you’re an active individual with type 1 diabetes, you must balance all your dietary choices before, during, and after exercise to manage blood glucose levels not to just prevent lows or highs, but also for optimal performance and recovery from working out or competing. It’s possible to eat many different ways including low-carbohydrate (5), and the best nutritional practices to optimize performance may or may not be best for blood glucose management, optimal health, and body weight simultaneously, potentially making achievement of athletic and health goals difficult at times.

As for insulin dosing, people vary so much with regard to their usual doses, insulin sensitivity, types of insulin used (basal and bolus choices), delivery (that is, insulin pump use vs. injections or inhalation), and more. It makes the whole balancing act that much more difficult, especially when blood glucose responses vary with the type of activity being done, including how long, how hard, how often, and under which environmental conditions. Even hydration status matters! Given how limited studies by nature must be to limit all these conditions, it takes individual trial-and-error to figure out what works best to maintain blood glucose levels in a fairly tight (and hopefully normal) range for each and every unique activity bout.

Many insulin users have still managed to figure out how to compete athletically at the highest levels, although it is far from simple when balancing blood glucose levels with these many confounding variables (6). It’s certainly still worth it to be physically active with type 1 diabetes, just a challenge!

References:

  1. Eckstein ML, McCarthy O, Tripolt NJ, et al. Efficacy of carbohydrate supplementation compared with bolus insulin dose reduction around exercise in adults with type 1 diabetes: A retrospective, controlled analysis. Can J Diabetes, 2020 (in press), https://doi.org/10.1016/j.jcjd.2020.03.003.
  2. Colberg SR, Nutrition and exercise performance in individuals with type 1 diabetes. Can J Diabetes, 2020 (in press), https://doi.org/10.1016/j.jcjd.2020.05.014.
  3. Bell KJ, King BR, Shafat A, Smart CE. The relationship between carbohydrate and the mealtime insulin dose in type 1 diabetes. J Diabetes Complications. 2015;29(8):1323-9, https://doi.org/10.1016/j.jdiacomp.2015.08.014.
  4. Bell KJ, Smart CE, Steil GM, Brand-Miller JC, King B, Wolpert HA. Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes Care. 2015;38(6):1008-15, https://doi.org/10.2337/dc15-0100.
  5. Scott SN, Anderson L, Morton JP, Wagenmakers AJM, Riddell MC. Carbohydrate restriction in type 1 diabetes: A realistic therapy for improved glycaemic control and athletic performance? Nutrients. 2019;11(5):1022, https://doi.org/10.3390/nu11051022.
  6. Riddell MC, Scott SN, Fournier PA, et al. The competitive athlete with type 1 diabetes [published online ahead of print, 2020 Jun 12]. Diabetologia. 2020;10.1007/s00125-020-05183-8, https://doi.org/10.1007/s00125-020-05183-8.

5 Key Strengthening Exercises for People with Diabetes

Although stay-at-home restrictions are loosening around the USA and summer is coming, you may still need to get some of your activities indoors at home for a variety of reasons. If you aren’t doing resistance workouts already, you should really consider adding some resistance exercises to your normal regimens.

In fact, if you do nothing else, doing these 5 key exercises is critical for people with diabetes who may have weak core muscles, altered gait and balance, and central and peripheral nerve damage.  If you lose your core strength, it will affect your ability to do all activities of daily living, including walking and living independently.

Do at least one set of 8-15 reps of each one, but work up to doing 2-3 sets of each one per workout.  For best results, do these exercises at least 2 or 3 nonconsecutive days per week — muscles need a day or two off to fully recover and get stronger — but just don’t do them right before you go do another physical activity (as a fatigued core increases your risk of injury). 

These and many more exercises are available on Diabetes Motion Academy for free download. You will find all the illustrations for the following exercises here as well.

Exercise 1: Crunches with waist worker

Exercise 2: Chair sit-ups OR Low back strengthener

Exercise 3: Modified push-ups

Exercise 4: Squats OR Suitcase lifts

Exercise 5: Sit-to-Stand exercise

#1: Crunches with waist worker

Crunches:

Directions:

•     Lie down on your back with your knees bent.

•     Place your hands on your head right behind your ears.

•     While breathing out, contract your abdominal muscles to lift your head, neck, and shoulders off the floor and curl forward no more than 45 degrees.

•     Hold for a moment before returning to the starting position, then repeat.

Waist worker:

Directions:

•     Lie on your back on the mat with your legs bent, your feet flat on the floor, and your left hand behind your head.

•     Stretch your right hand across your body toward your opposite (left) knee and circle your hand three times around your knee in a counterclockwise direction; your right shoulder blade will lift off the mat.

•     Repeat the circular movement around the right knee using your left arm, but in a clockwise motion.

•     Keep your head in a neutral position and relax your neck to ensure that the contraction is in your abdomen area only.

#2: Chair sit-ups OR Low back strengthener

Chair sit-ups:

Directions:

•     Sit up straight in a chair with your feet on the floor, hands to your sides for support.

•     Bend forward, keeping your lower back as straight as possible, moving your chest down toward your thighs.

•     Slowly straighten back up, using your lower back muscles to raise your torso.

•     For added resistance, put a resistance band under both feet before you start and hold one end in each hand during the movement.

            OR

Low back strengthener (Superman exercise):

Directions:

•     Lie on your stomach with your arms straight over your head, your chin resting on the floor between your arms.

•     Keeping your arms and legs straight, simultaneously lift your feet and your hands as high off the floor as you can (aim for at least three inches off the floor).

•     Hold that position (sort of a Superman flying position) for 10 seconds if possible, and then relax your arms and legs back onto the floor.

•     If this exercise is too difficult to start, try lifting just your legs or arms off the floor separately–or even just one limb at a time.

#3: Modified push-ups

Directions:

•     Get on your hands and knees on the floor or mat.

•     If using a band for extra resistance, position it across your back and hold one end of it in each hand so that it is somewhat tight when your elbows are straight.

•     Place your hands shoulder-width apart on the mat.

•     Tighten your abdominal muscles to straighten your lower back and lower yourself (from your knees, not your feet) down toward the mat as far as you can without touching it.

•     Push yourself back up until your arms are extended, but without locking your elbows.

•     If this exercise is too hard, stand facing a wall and place your arms on it at shoulder height and your feet about a foot away; then, do your push-ups off the wall (with or without a resistance band).

#4: Squats OR Suitcase Lifts

Squats:

Directions:

•     Stand with a dumbbell (or household item, like water bottles) in each hand and your feet shoulder-width apart, with your toes pointing slightly out to the side.

•     If you’re using a resistance band, tie both ends of your band onto a straight bar or broom handle, which is placed squarely across your shoulders with the loop of the tied band placed under your feet.

•     Keep your body weight over the back portion of your foot rather than your toes; if needed, lift your arms out in front of you to shoulder height to balance yourself.

•     Begin squatting down but stop before your thighs are parallel to the floor (at about a 70-degree bend), keeping your back flat and your abdominal muscles firm at all times.

•     Hold that position for a few seconds before pushing up from your legs until your body is upright in the starting position.

•     Do squats with your back against a smooth wall if needed to maintain your balance.

OR

Suitcase lift:

Directions:

•     After placing dumbbells (or household items) slightly forward and between your feet on the floor, stand in an upright position with your back straight.

•     Keep your arms straight, with your hands in front of your abdomen.

•     With your back straight, bend only your knees and reach down to pick up the dumbbells.

•     Pick up the dumbbells or items in both hands, then push up with your legs and stand upright, keeping your back straight.

#5: Sit-to-Stand exercise

Directions:

•     Sit toward the front of a sturdy chair and fold your arms across your chest.

•     Keep your back and shoulders straight while you lean forward slightly and practice using only your legs to stand up slowly and to sit back down.

•     To assist you initially, place pillows on the chair behind your low back.

From Diabetes Motion Academy Resources, Sheri R. Colberg © 2020.

Manage Your Stress with Some At-Home Flexibility Exercises

Hamstring stretch illustratedFeeling stressed out by the pandemic or by being trapped at home with no end in sight? If you’re a regular exerciser like me, the closure of gyms and fitness centers in most parts of the country may be limiting your options to de-stress by being active. Take a few minutes each day and work on your flexibility with these simple exercises you can do at home. These and many more illustrated exercises are available on Diabetes Motion Academy for free download.

Flexibility exercises in their simplest form stretch and elongate muscles. Good flexibility is as important a part of fitness as stamina. Muscles must be strong, but they also have to be long (as opposed to contracted) to work optimally. In fact, stretching can do a lot more for your figure than aerobic exercise because flexibility work results in a supple, toned, and streamlined body. Moreover, the benefits of greater flexibility may go beyond the physical to include stress reduction and promotion of a greater sense of well-being. Exercise disciplines which incorporate stretching with breath control and meditation include yoga, tai chi, and Pilates.

In creating your flexibility workouts and completing them a minimum of 2-3 times a week, it’s again important to include stretches for all of the major muscle groups in your body. You will regain some of your flexibility by stretching regularly, although your gains may be ultimately limited by your genetic makeup, arthritis, metabolic control, and other variables. Nonetheless, even people with type 2 diabetes experience flexibility gains by doing just eight weeks of stretching of their major upper- and lower-body muscles thrice weekly in conjunction with a moderate resistance training program, so likely everyone will benefit to some degree from regular flexibility training and from moving their joints through their full range of motion.

Flexibility Training “Do’s” and “Don’ts”

Do:

  • Use a full range of motion around joints when stretching
  • Complete at least one stretch per major muscle group, optimally holding each stretch for 15 to 30 seconds
  • Stretch all parts of your body two to three days per week
  • Complete equal stretching exercises on both sides of your body or a joint
  • Breathe deeply during all stretches to relax your muscles more

Don’t:

  • Bounce during stretches, as doing so can cause muscle tears and joint injuries
  • Forget to stretch opposing muscle groups equally (e.g., quads and hamstrings)
  • Stretch to the point of causing sharp pain or intense discomfort
  • Continue with a stretch if you feel a sharp or immediate pain in any joint or muscle
  • Hold your breath or strain while stretching

To get the maximum benefit from static stretching, perform each stretch slowly. Doing the exercises correctly, with good form, is much more important than doing them quickly. To have any lasting effect on the muscle being stretched, you need to hold the stretch for at least 10 seconds to start. The more regularly you stretch, the better you become at judging how far to take your body. Aim to increase the duration of your stretches, so that you are eventually able to hold them for up to 30 seconds, the point at which muscles optimally start to lengthen. Also, be sure to stretch both sides of your body equally, as well as opposing muscles on both sides of a joint (such as biceps and triceps on the upper arm).

Download the free, printable PDF for illustrations and instructions of these flexibility exercises:

 

Upper-Body Stretches

#1: Neck stretch

#2: Shoulder/upper back stretch

#3: Chest/shoulder stretch

#4: Shoulder/biceps stretch

#5: Upper back/triceps stretch

#6: Wrist stretch

 

Lower-Body Stretches

#1: Quad (front of thigh) stretch

#2: Hamstring (back of thigh) stretch

#3: Alternate hamstring (back of thigh) stretch

#4: Gluteal (bottom) stretch

#5: Calf stretch

#6: Ankle stretch

 

Other Stretches

#1: Abdominal stretch

#2: Back/gluteal stretch

#3: Complete back (cat) stretch

#4: Total body stretch

                                                                                                                                               

From Diabetes Motion Academy Resources, “Flexibility Exercises,” Sheri R. Colberg © 2017.

Exercising in a Pandemic: 10 Easy Exercises to Build a Strong Core Without Leaving the House

Pelvic tilt

Just in time for the novel coronavirus (COVID-19) social distancing and closures of gyms and fitness centers in many areas, here’s a revisit of many important core exercises you can do at home to keep yourself strong and healthy. Download the free illustrated PDF (Chapter 21) for illustrations. You can also find a variety of other at-home exercises on Diabetes Motion Academy Resources for free download.

Many people are stuck at home for one reason or another think they can’t work on staying fit, but the truth is that you can get a stronger core and stay fitter without leaving home. You’d be amazed at how easy it is to get your fit on.

Remember: Your body core — the muscles around your trunk and pelvis — is particularly important to keep strong so that you can go about your normal daily activities and prevent falls and injuries, particularly as you age. Having a strong body core makes you better able to handle your daily life, even if that’s just doing grocery shopping or playing a round of golf.

Core exercises are an important part of a well-rounded fitness program, and they’re easy to do at home on your own. To get started on your body core workout, you don’t need to purchase anything. (Some of the advanced variations do call for equipment like a gym ball or dumbbells.)

Tip: Include all 10 of these easy core exercises in your workouts, doing at least one set of 15 repetitions of each one to start (where appropriate). Work up to doing two to three sets of each per workout, or even more repetitions if you can. For best results, do these exercises at least two or three nonconsecutive days per week; muscles need a day or two off to fully recover and get stronger. Just don’t do them right before you do another physical activity (because a fatigued core increases your risk of injury).

#1: Abdominal Squeezes

This exercise (Figure 21-1) is great for working your abdominals and getting your body core as strong as possible. If you’re female and have had gone through a pregnancy at some point, getting these muscles in shape doing these squeezes is a must.

  1. Put one of your hands against your upper stomach and the other facing the other direction below your belly button.
  2. Inhale to expand your stomach.
  3. Exhale and try to pull your abdominal muscles halfway toward your spine.

This is your starting position.

  1. Contract your abdominal muscles more deeply in toward your spine while counting to two.
  2. Return to the starting position from Step 3 for another count of two.

Work up to doing 100 repetitions per workout session.

#2: Planks or Modified Planks

Nobody likes doing planks, but they get the job done when it comes to boosting the strength of your core. Both planks and modified planks (Figure 21-2) work multiple areas, including your abdominals, lower back, and shoulders.

  1. Start on the floor on your stomach and bend your elbows 90 degrees, resting your weight on your forearms.
  2. Place your elbows directly beneath your shoulders and form a straight line from your head to your feet.
  3. Hold this position as long as you can.

Repeat this exercise as many times as possible during each workout.

#3: Side Planks

A modification of regular planks, this side plank exercise (Figure 21-3) works some of the same and some slightly different muscles that include your abdominals, oblique abdominal muscles, sides of hips, gluteals, and shoulders. Try doing some of both types for the best results.

  1. Start out on the floor on your side with your feet together and one forearm directly below your shoulder.
  2. Contract your core muscles and raise your hips until your body is in a straight line from head to feet.
  3. Hold this position without letting your hips drop for as long as you can.
  4. Repeat Steps 1 through 3 on the other side.

Switch back and forth between sides as many times as you can.

Tip: Try these plank variations to mix things up a bit:

* Raised side plank: Lifting both your top arm and your leg upward brings other muscles into play and makes your core work harder to maintain balance, but don’t let your hips sag.

* Gym ball side plank: Resting your supporting arm on a gym ball, use your core muscles to control the wobble to further strengthen your side muscles.

* Side plank with lateral raise: While holding the side plank position, slowly raise and lower a light dumbbell or other weight with your top arm to improve your coordination and strength.

* Side plank pulse: From the side plank position, add a vertical hip drive by lowering your hips until they’re just off the floor and then driving them up as far as you can with each repetition of this move.

#4: Bridging

If you work on your abdominal strength, you also need to build the strength in your lower back to keep things balanced. Bridging (Figure 21-4) is a good exercise to do that as it works your buttocks (including gluteals), low back, and hip extensors. Remember to breathe in and out throughout this exercise.

  1. Slowly raise your buttocks from the floor, keeping your stomach tight.
  2. Gently lower your back to the ground.
  3. Repeat Steps 1 and 2.

Tip: Try the bridging with straight leg raise variation: With your legs bent, lift your buttocks up off the floor. Slowly extend your left knee, keeping your stomach tight. Repeat with the other leg. Do as many repetitions as possible.

#5: Pelvic Tilt

An easy exercise to do, the pelvic tilt (Figure 21-5) works your lower back and
lower part of your abdominals.

  1. Lie on your back on the floor with your knees bent and feet flat on the floor.
  2. Place your hands either by your sides or supporting your head.
  3. Tighten your bottom, forcing your lower back flat against the floor, and then relax.
  4. Repeat Steps 2 and 3 as many times as you can.

#6: Superhero Pose

Whether you want to leap a tall building with a single bound or not, try doing this superhero pose exercise (Figure 21-6) to get a stronger core. It works many areas, including your lower back, upper back, back of shoulders, and gluteals.

  1. Lie on your stomach with your arms straight over your head.
  2. Rest your chin on the floor between your arms.
  3. Keeping your arms and legs straight, simultaneously lift your feet and your hands as high off the floor as you can.

Aim for at least three inches.

  1. Hold that position (sort of a superhero flying position) for 10 seconds if possible, and then relax your arms and legs back onto the floor.

Tip: If this exercise is too difficult, try lifting just your legs or arms off the floor separately — or even just one limb at a time.

#7: Knee Push-Ups

Push-ups are hard to do if you haven’t built up the strength in your shoulders yet, so this knee version (Figure (21-7) is an easier way to start for most people. This exercise works your chest, front of shoulders, and back of upper arms.

  1. Get on your hands and knees on the floor or a mat.
  2. Place your hands shoulder-width apart on the floor.
  3. Tighten your abdominal muscles to straighten your lower back and lower yourself down toward the floor as far as you can without touching.
  4. Push yourself back up until your arms are extended, but don’t lock your elbows.

Tip: If knee push-ups are too hard for you, try doing wall push-ups to start instead. Stand facing a wall at an arm’s length and place your palms against it at shoulder height and with your feet about a foot apart. Do your push-ups off the wall.

#8: Suitcase Lift

This exercise (Figure 21-8) is the proper way to lift items from the floor. Before you begin, place dumbbells or household items slightly forward and between your feet on the floor. You work the same muscles used in doing squats (lower back and lower body) with this activity.

  1. Stand in an upright position with your back and arms straight, with your hands in front of your abdomen.
  2. Bending only your knees, reach down to pick up the dumbbells.
  3. Grab the dumbbells or items in both hands and then push up with your legs and stand upright, keeping your back straight.

#9: Squats with Knee Squeezes

These squats (Figure 21-9) are not your normal squats. They’re more like a combination of squatting and wall sitting with a twist. You work the front and back of thighs, inner thighs (adductors), hip flexors and extensors all with this one exercise.

  1. Stand with your back against the wall, with your feet aligned with your knees and straight out in front of you.
  2. Place a ball or pillow between your knees and hold it there with your legs.
  3. Inhale to expand your stomach and then exhale and contract your abdominal muscles.
  4. Bend your knees and lower yourself into a squat.

Warning: To avoid injuring your knees, don’t bend them more than 90 degrees.

  1. Squeeze the ball with your thighs, drawing your stomach muscles more deeply toward your spine.
  2. Do as many squeezes as you can up to 20 and then return to the starting position.

#10: Lunges

Lunges (Figure 21-10) are a common activity to work on the front and back of thighs, hip flexors and extensors, abdominals, and lower back all with one exercise. Do them with proper form to avoid aggravating your knees, though.

  1. Keep your upper body straight, with your shoulders back and relaxed and chin up.
  2. Pick a point to stare at in front of you so you don’t keep looking down, and engage your core.
  3. Step forward with one leg, lowering your hips until both knees are bent at about a 90-degree angle.

Make sure your front knee is directly above your ankle, not pushed out too far, and don’t let your back knee touch the floor.

  1. Focus on keeping your weight on your heels as you push back up to the starting position.

Tip: To prevent injuries, if you feel any pain in your knees or hips when you do a lunge, do the following instead:

  • Take smaller steps out with your front leg.
  • Slowly increase your lunge distance as your pain gets better.
  • Try doing a reverse lunge (stepping backward rather than forward) to help reduce knee strain.

                                                                                                                                               

Excerpted from Colberg, Sheri R., Chapter 21, “Ten Easy Exercises to Build a Strong Core Without Leaving the House” in Diabetes & Keeping Fit for Dummies. Wiley, 2018.