Increasing Insulin Sensitivity

This post is an excerpt of my article that appeared in Diabetes Self-Management in the March/April 2007 issue, but was recently posted online.

Insulin is a hormone that is normally released by the beta cells of the pancreas. When a person’s pancreas cannot produce enough insulin to sustain good health, insulin can be injected into the body with a needle or infused with a pump.

One of the main functions of insulin is to lower blood glucose levels by enabling glucose to enter the cells of the body, where it is used for energy or stored for future use. A person who is insulin-sensitive needs only a relatively small amount of insulin to keep blood glucose levels in the normal range and to keep the body’s cells supplied with the glucose they need. A person who is insulin-resistant, on the other hand, needs a lot more insulin to get the same blood-glucose-lowering effects.

Insulin resistance is associated with numerous health risks. For one thing, it causes hyperinsulinemia, or high circulating insulin levels, which may be directly damaging to blood vessels. Hyperinsulinemia is also associated with high blood pressure, heart disease and heart failure, obesity (particularly abdominal obesity), osteoporosis (thinning bones), and certain types of cancer, such as colon, breast, and prostate cancer. In contrast, having low circulating insulin levels is associated with greater longevity; most centenarians without diabetes have low circulating insulin levels.

Insulin resistance is a hallmark of Type 2 diabetes, but it can occur in Type 1 diabetes as well. In fact, there is a growing number of people who are said to have “double diabetes” because, in addition to having Type 1 diabetes, they also have the insulin resistance characteristic of Type 2.

The good news is that you can lower your level of insulin resistance — and raise your level of insulin sensitivity — by modifying your lifestyle choices, particularly your exercise and eating choices, regardless of the type of diabetes you have.

How physical activity helps
Physical activity has a significant positive effect on insulin sensitivity. Indeed, it may have the biggest effect of any measure you could take to improve your insulin sensitivity. Any type of physical activity has the potential to make your insulin work better, and combining aerobic activities — such as brisk walking, swimming, and cycling — with resistance training, or weight training, appears to have the greatest effect. Aerobic activities burn more calories (and glucose) per session, but resistance training builds muscle, which is what burns glucose during exercise, so having more is better.

Numerous studies bear out the value of physical activity and exercise in improving insulin sensitivity. In a study of lean, sedentary, young adult women (ages 18–35), both six months of thrice-weekly aerobic training and six months of resistance training improved glucose use in the body.

In another study, sedentary, insulin-resistant, middle-aged adults who engaged in 30 minutes of moderate walking three to seven days per week for six months succeeded in reversing their insulin resistance — without changing their diets or losing any body weight (although their body proportions of fat and muscle likely changed for the better).

In a study of older adults in their 70’s, low- to moderate-intensity “walking” on a mini-trampoline for 20–40 minutes four days per week over a four-month period enhanced their glucose uptake by cells without any additional insulin release by the pancreas or loss of abdominal fat.

No matter what your age, weight, or current level of physical fitness, studies have shown that exercise training can improve your insulin sensitivity within just one week of training without weight loss.

Types of training
While combined aerobic and resistance training is recommended for everyone, the benefits you will reap from any given activity will depend on how fit you currently are. If you’re completely sedentary now, starting a walking program or moderate resistance training program will initially be effective enough. If you’re already doing regular aerobic exercise, you will likely benefit more from adding some interval training or resistance training to your exercise routine. In interval training, you intersperse periods of intense exercise with periods of slower, easier activity. For example, on a stationary bike, you might pedal faster and harder for 30–60 seconds, then pedal at a moderate pace for a few minutes, then repeat this pattern throughout your exercise session.

Once again, research confirms that this approach works. In a recent study of previously sedentary people with Type 2 diabetes, four to six weeks of moderate-intensity resistance training improved their insulin sensitivity by 48%, even without causing any significant changes in their body fat or muscle mass. Similarly, unfit men who were newly diagnosed with Type 2 diabetes who did 16 weeks of “progressive” resistance training (meaning that the weight they lifted was increased over time) just twice a week gained muscle mass, lost body fat (particularly in the abdominal region), and greatly enhanced their insulin sensitivity — all despite a 15% increase in the amount of calories they consumed.

For older women with Type 2 diabetes, studies have shown that the combination of aerobic and resistance training may afford even greater improvements in insulin sensitivity and a more significant decrease in abdominal fat than aerobic training alone, with increased muscle mass to boot.

Maximizing the effects
The exercise studies mentioned so far all examined the effects of longer-term training, but each bout of exercise also exerts its own effect. During exercise, your body burns glycogen, a form of glucose that is stored in your muscles. After exercise, your muscles replenish their glycogen stores with glucose from the bloodstream. The more glycogen that is burned during a bout of activity, the longer the body’s insulin sensitivity is improved.

More intense and longer-duration activities can improve insulin sensitivity for up to one to two days, as muscle glycogen that was used during the exercise is being restored. A short, low-intensity activity such as weeding a small garden, however, may not have any lasting impact on insulin sensitivity since very little glycogen is used during it.

Therefore, to improve insulin sensitivity on a continuing basis, you should plan on exercising at least every other day, with near-daily workouts exerting an even more beneficial effect. In addition, you should try to do some more intense workouts (like brisk walking and resistance work) in addition to normal, less strenuous daily activities.

For example, in a recent study of older individuals with diabetes, even when they were already walking at least 10,000 steps a day, their fitness and diabetes control benefited from doing “pick up the pace” training that consisted of walking at a 10% faster pace for 30 minutes three days a week. For a person who usually takes 90 steps per minute, walking 10% faster would mean taking 99 steps per minute instead.

Planning your daily activities
Given that the effects of more intense or longer-duration exercise may last slightly longer, the best plan is to intersperse these types of workouts throughout your week, or to do a more intense activity every other day to maximize its insulin-enhancing effects. Alternating between more challenging activities and easier or more moderate activities is a good way to keep yourself motivated, prevent athletic injuries, and keep your exercise training on track.

The major reasons that people stop (or fail to begin) regular exercise are perceived lack of time, injuries from workouts, inconvenience, loss of motivation, and difficulty of workouts. By varying your activities from day to day, you can fit in whatever you have time for more easily, you’re less likely to injure yourself, you can pick activities that are convenient for you on any given day, your motivation is likely to stay higher, and the exercise won’t feel too hard for you since you’ll have plenty of time to recover between more intense workouts.

To improve your insulin sensitivity, aerobic training should either be more intense for an extended period of time (such as during the “pick up the pace” training mentioned earlier) or just during interspersed intervals (like periodically walking faster between two mailboxes or telephone poles) during the whole activity.

Resistance work (with weights or rubber resistance bands) will benefit you the most if you build up to a weight or resistance that you can lift with good form at least 8 times but not more than 12 times in each set. (Plan to do one to three sets of 8–12 repetitions per exercise.) When you’re first starting out with resistance training, however, it’s OK to work with lighter weights or less resistance while you familiarize yourself with the equipment and exercises.

Varying the types of exercise you do and the intensity with which you do them will improve your fitness and your insulin sensitivity the most. However, each person needs to find his own comfort level. What is “challenging,” “moderate,” or “easy” for you will depend on your current level of fitness. A sample weekly plan follows:

DAY 1: [Challenging aerobic] 30–60 minutes of any type of aerobic training either done at a faster pace or with faster intervals interspersed in the activity

DAY 2: [Moderate resistance] 10-minute aerobic warm-up (easy exercise), followed by 30–45 minutes of resistance training using the major muscle groups of the upper and lower body (at least one set of 8–12 repetitions)

DAY 3: [Easy aerobic] Regular activities of daily living, with the goal of taking at least 10,000 steps (counted with a pedometer) at any pace

DAY 4: [Challenging aerobic] 30–60 minutes of aerobic training either done at a faster pace or with faster intervals interspersed in the activity

DAY 5: [Moderate resistance] 10-minute aerobic warm-up (easy exercise), 30–45 minutes of resistance training (at least one set of 8–12 repetitions)

DAY 6: [Easy aerobic] Regular activities of daily living (at least 10,000 steps at any pace)

DAY 7: [Rest] Day with no planned activities

WEEKLY GOALS: Include at least 2 days of resistance (strength) training and 2 days of harder, more intense aerobic workouts spaced out evenly throughout the week, along with as much daily activity as possible on almost all days of the week.

Other insulin sensitizers
In addition to performing more physical activity, losing excess body fat is well known to improve insulin sensitivity, and other factors can help, too. For instance, avoiding elevated blood glucose levels after meals can improve your insulin sensitivity. You can prevent such elevations by choosing foods with a higher fiber content and lower glycemic index and glycemic load (such as vegetables and legumes) and, if you take insulin, adjusting your premeal doses according to the amount of carbohydrate in the meal. Exercising just before meals can also help to lower after-meal blood glucose levels since insulin sensitivity is heightened right after exercise.

You can also lower your insulin resistance by getting enough sleep, moderating your stress levels (exercise can help with this), and reducing your body’s level of inflammation (which can also be accomplished through physical activity and better food choices).

Many things will increase insulin sensitivity, and most can be accomplished through lifestyle changes. Here are some insulin sensitizers to consider:

  • Regular aerobic and resistance exercise
  • Increase in muscle mass
  • Loss of body fat, particularly intra-abdominal (or visceral) fat, extra fat stored in the liver, and possibly excess fat in muscles
  • Improved blood glucose control and avoidance of highs and lows
  • Reduced levels of circulating fats in blood, including triglycerides and free fatty acids
  • Reduction in low-level, systemic inflammation, which can be accomplished through physical activity and eating foods rich in antioxidants, such as darkly colored fruits and vegetables
  • More effective action of leptin, a hormone released by fat cells, causing reduced food intake. This can be accomplished through increased physical activity and loss of excess body fat.
  • Reduction in mental and physical stressors, such as anxiety, depression, or illness
  • Decrease in circulating levels of cortisol, a hormone released in response to all forms of stress
  • In men, increased testosterone levels, which can be accomplished through increased activity levels
  • Increased intake of dietary fiber; decreased consumption of saturated and trans fat and highly refined foods with high glycemic index values
  • Daily consumption of a healthy breakfast
  • Lower caffeine intake. Clinical trials examining the effects of caffeine (but not coffee) have shown that ingesting the amount of caffeine in about three cups of coffee lowers insulin sensitivity. However, coffee itself contains compounds that may offset this effect. For those who like coffee, the best approach may be to drink decaf, since it contains the “offsetting” compounds without the caffeine.
  • Adequate sleep (seven to eight hours a night for most adults)
  • Effective treatment of sleep apnea
  • Use of insulin-sensitizing medicines such as pioglitazone (Actos) or rosiglitazone (Avandia)
  • You can exert a large amount of control over how effectively your insulin works in your body, and being insulin sensitive has many health benefits. If you take insulin, a heightened sensitivity may allow you to lower your insulin doses. If you take insulin-sensitizing oral medicines, these prescriptions will work more effectively, and you may also end up requiring smaller doses. Regardless of any medicines you take, improving your insulin sensitivity — particularly when you accomplish this goal through increased and varied physical activity — is a winning proposition for your diabetes control and your overall health.


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