Author Archives: Sheri Colberg, PhD

About Sheri Colberg, PhD

Dr. Sheri Colberg is an exercise physiologist with a world of experience with diabetes, exercise, and more. As a diabetic exerciser and researcher, she knows the latest about physical activity and its effects on your body, whether you have diabetes or not.

Are My Joint Issues Due to Being Active, Normal Aging, or Diabetes?

Sheri DHHS 30th climbing side viewLiving with diabetes often leads me to wonder if what I’m experiencing—particularly when it’s an irritated joint or an overuse injury—is a consequence of being a regularly physically active person, getting older, or having diabetes, or some combination of those. Which one of these is causing my joint issues? Is it possible to know? I will attempt to answer these questions based on my deeper dive into the published research.

Personally, I have managed to avoid most overuse injuries (such as joint tendinitis) related to physical activity by engaging in cross-training and doing different activities on varying days, and this strategy worked well for me for over 25 years. Of late, though, I have started experiencing chronic overuse injuries (or sometimes just short-term joint irritation) that appear to arise not from most of my usual activities, but more from unusual ones—such as hand-scrubbing my house to get it ready to sell (dominant shoulder joint irritation), tamping down my front yard with a hand compactor (alternate shoulder joint pain that lasted for several years and recurs occasionally), driving a car for several hours in traffic after not driving far often (ankle joint tendinitis of some sort that took months to fully resolve), and random aches and pains in joints that come and go on any given day and may only last a few days at most.

Yes, I’m getting older (aren’t we all?), having successfully passed the half-century mark. I’ve also been living with type 1 diabetes for nearly 50 years (diagnosed at age four in 1968). My A1Cs are in recommended ranges (usually near 6.0%) and have been good ever since I got my first blood glucose meter in 1986 (after going 18 years with nothing but urine testing). I still have blood glucose fluctuations while trying to manage food, exercise, stress, occasional lack of sleep, hormonal variations, illness, and other usual factors that impact my daily levels. So, are my own occasional joint issues the result of being an active person (exercising daily for decades), normal aging, or long-standing diabetes (despite being in relatively good control for the past 30+ years)?

Are overuse injuries more likely to occur due to diabetes or aging? Overuse injuries from participation in athletic endeavors (even just walking) are more common in people with diabetes, likely due to changes in joint structures when exposed to hyperglycemia over time (1). But aging also increases the incidence of overuse injuries when exercisers are older (2). For instance, in one study 70% of the injuries in older exercisers (over 60 years) were overuse injuries, but accounted for only 41% of injuries in younger adults (early 20s).

Is it due to inflammation related to aging or to diabetes? Aging lab rats have overuse activity changes to the structure of their tendons related to inflammation that may make them more prone to injury (3), but when it comes to humans, the research is unclear whether inflammation is involved (4). In one review (5), “prolonged systemic, low-grade inflammation and impaired insulin sensitivity act as a risk factor for a failed healing response after an acute tendon insult and predispose to the development of chronic overuse tendinopathies.” Perhaps, then, in people with diabetes, joint structures do not respond as well to or repair as quickly after activities (6).

Others have argued that low-level, systemic inflammation is not involved in changes to tendons that may lead to injury (4). People with diabetes have some structural joint changes that may or may not be related to diabetes duration or type, although poorer blood glucose management has been associated with higher levels of systemic inflammation (1). Fit, active adults with type 1 diabetes with good blood glucose control exhibit more inflammatory markers in response to exercise, but appear to recover normally (7). If someone has had “good” control for many years, does that lower the chance that their overuse injuries are diabetes-related? I’m quickly raising more questions than I can answer!

Other joint issues like frozen shoulder, carpal tunnel syndrome, and trigger finger are more common in people with diabetes, and structural changes to tendons may occur in people with diabetes (8). On the other hand, my non-diabetic, aging (mid-50s), reasonably active neighbor has had two frozen shoulders in recent years that clearly have nothing to do with diabetes or blood glucose management. I’ve also known people with diabetes who are active that develop a frozen shoulder, but others who get this condition are sedentary, suggesting that such joint issues are not consistently related to diabetes or habitual physical activity.

In short, if you are reading this in hopes of finding out whether joint pains and overuse injuries are more related to being active, aging, or diabetes, you are about to be sorely disappointed because I am unable to determine that based on available research. That said, it is likely that getting older (and not springing back as quickly) contributes to the rise in overuse injuries with aging, but that just means that everyone will have to find ways to be active that do not aggravate any existing issues. The best policy still is to vary your activities, try not to overdo or act like you’re still twenty, and rest appropriately and take time off when necessary to recover from injuries. Given we’re all aging and a significant number of us will be developing diabetes in our later years (if we don’t have it already), it is a topic ripe with possibility for future research.

                                                                                                                                                           

References cited:

  1. Abate M, Schiavone C, Salini V, Andia I: Management of limited joint mobility in diabetic patients. Diabetes Metab Syndr Obes 2013;6:197-207
  2. Kannus P, Niittymaki S, Jarvinen M, Lehto M: Sports injuries in elderly athletes: a three-year prospective, controlled study. Age Ageing 1989;18:263-270.
  3. Kietrys DM, Barr-Gillespie AE, Amin M, Wade CK, Popoff SN, Barbe MF: Aging contributes to inflammation in upper extremity tendons and declines in forelimb agility in a rat model of upper extremity overuse. PLoS One 2012;7:e46954. doi: 46910.41371/journal.pone.0046954.
  4. Kjaer M, Bayer ML, Eliasson P, Heinemeier KM: What is the impact of inflammation on the critical interplay between mechanical signaling and biochemical changes in tendon matrix? 1985) 2013;115:879-883. doi: 810.1152/japplphysiol.00120.02013.
  5. Del Buono A, Battery L, Denaro V, Maccauro G, Maffulli N: Tendinopathy and inflammation: some truths. Int J Immunopathol Pharmacol 2011;24:45-50.
  6. Battery L, Maffulli N: Inflammation in overuse tendon injuries. Sports Med Arthrosc 2011;19:213-217. doi: 210.1097/JSA.1090b1013e31820e31826a31892.
  7. West DJ, Campbell MD, Gonzalez JT, Walker M, Stevenson EJ, Ahmed FW, Wijaya S, Shaw JA, Weaver JU: The inflammation, vascular repair and injury responses to exercise in fit males with and without Type 1 diabetes: an observational study. Cardiovasc Diabetol 2015;14:71
  8. de Jonge S, Rozenberg R, Vieyra B, Stam HJ, Aanstoot HJ, Weinans H, van Schie HT, Praet SF: Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study. Br J Sports Med 2015;49:995-999. doi: 910.1136/bjsports-2014-093696.
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What Do We Really Know about Exercising with Complications?

Back injury

As a clinical exercise researcher, I frequently have found it difficult to study exercise effects in people with health complications, even though this is critical information to know in order to make appropriate exercise guidelines. Try convincing your university Institutional Research Board, or IRB, that it is advisable to exercise people with eye issues like unstable proliferative retinopathy to find out if breath-holding, jumping, jarring, or head-down activities cause them to experience retinal hemorrhages. Understandably, that is not going to happen, nor should it.

In some cases, I have not even been allowed to study relevant populations—like when we wanted to study older adults with type 2 diabetes and balance or gait issues related to peripheral neuropathy. Our IRB required so many exclusionary criteria that we were only able to recruit healthy, older subjects with diabetes, not the ones for whom an exercise training intervention to improve balance would be most relevant (i.e., those with actual balance issues).

It is still worth revisiting the latest recommendations for exercising safely and effectively with a variety of diabetes-related health complications. Most of these are derived from clinical observations and practical experience rather than clinical studies, though. The table that follows is a compilation of all these recommendations. (Please access the entire ADA Position Statement online, including redacted references, at http://care.diabetesjournals.org/content/39/11/2065).

Table 5: Physical activity consideration, precautions, and recommended activities for exercising with health-related complications (Modified from (1))

Health Complication Exercise Considerations Physical Activity Recommendations/Precautions
Cardiovascular Diseases
Coronary Artery Disease (heart disease) Coronary perfusion may actually be enhanced during higher intensity aerobic or resistance exercise All activities okay; consider exercising in a supervised cardiac rehabilitation program, at least initially
Exertional Angina (chest pain on exertion) Onset of chest pain on exertion, but exercise-induced ischemia may be silent in some with diabetes All activities okay, but heart rate should be kept 10 or more beats/min below onset of exercise-related angina
Hypertension (high blood pressure) Both aerobic and resistance training may lower resting blood pressure and should be encouraged; some blood pressure medications can cause exercise-related hypotension Ensure adequate hydration during exercise; avoid Valsalva maneuver during resistance training
Myocardial Infarction (heart attack) Stop exercise immediately should symptoms of myocardial infarction (such as chest pain, radiating pain, shortness of breath, and others) occur during physical activity and seek medical attention. Restart exercise post-MI in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Stroke Diabetes increases the risk of ischemic stroke; stop exercise immediately if symptoms of a stroke (occurring suddenly and often affecting only one side of the body) during exercise Restart exercise post-stroke in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Congestive Heart Failure Most common cause is coronary artery disease and frequently follows a myocardial infarction Avoid activities that cause an excessive rise in heart rate; focus more on doing low- or moderate-intensity activities
Peripheral Artery Disease Lower-extremity resistance training improves functional performance Low- or moderate-intensity walking, arm ergometer, and leg ergometer preferred as aerobic activities; all other activities okay
Nerve Disease
Peripheral Neuropathy Regular aerobic exercise may also prevent the onset or delay the progression of peripheral neuropathy in both type 1 and type 2 diabetes Proper care of the feet is needed to prevent foot ulcers and lower the risk of amputation; keep feet dry; use appropriate footwear, silica gel or air midsoles, and polyester or blend socks (not pure cotton); consider inclusion of more non-weight-bearing activities, particularly if gait altered
Local Foot Deformity Manage with appropriate footwear and choice of activities to reduce plantar pressure and ulcer risk Focus more on non-weight-bearing activities to reduce undue plantar pressures; examine feet daily to detect and treat blisters, sores, or ulcers early
Foot Ulcers/Amputations Moderate walking is not likely to increase risk of foot ulcers or re-ulceration with peripheral neuropathy Weight-bearing activity should be avoided with unhealed ulcers; examine feet daily to detect and treat blisters, sores, or ulcers early; amputation sites should be properly cared for daily; avoid jogging
Autonomic Neuropathy (central nerve damage) May cause postural hypotension, chronotropic incompetence, delayed gastric emptying, altered thermoregulation, and dehydration during exercise; exercise-related hypoglycemia may be harder to treat in those with gastroparesis With postural hypotension, avoid activities with rapid postural or directional changes to avoid fainting or falling. Those with cardiac autonomic neuropathy should have physician approval and possibly undergo symptom-limited exercise testing before commencing exercise. With blunted heart rate response, use heart rate reserve and ratings of perceived exertion (RPE) to monitor exercise intensity. With autonomic neuropathy, avoid exercise in hot environments and hydrate well.
Eye Diseases
Mild to Moderate Nonproliferative Retinopathy Individuals with mild to moderate nonproliferative changes have limited or no risk for eye damage from physical activity All activities okay with mild, but annual eye exam should be performed to monitor progression. With moderate non-proliferative retinopathy, avoid activities that dramatically elevate blood pressure, such as powerlifting
Severe Nonproliferative and Unstable Proliferative Retinopathy Individuals with unstable diabetic retinopathy are at risk for vitreous hemorrhage and retinal detachment Avoid activities that dramatically elevate blood pressure, such as vigorous activity of any type. Also avoid vigorous exercise, jumping, jarring, and head-down activities, and breath-holding. No exercise should be undertaken during a vitreous hemorrhage
Cataracts Cataracts do not impact the ability to exercise, only the safety of doing so due to loss of visual acuity Avoid activities that are more dangerous due to limited vision, such as outdoor cycling; consider supervision for certain activities
Kidney Disease
Microalbuminuria (micro bits of protein in urine) Exercise does not accelerate progression of kidney disease even though protein excretion acutely increases afterward. Greater participation in moderate-to-vigorous leisure time activity and higher physical activity levels may actually moderate the initiation and progression of diabetic nephropathy All activities okay, but vigorous exercise should be avoided the day before urine protein tests are performed to prevent false positive readings
Overt Nephropathy (protein in urine) Both aerobic and resistance training improve physical function and quality of life in individuals with kidney disease; individuals should be encouraged to be active All activities okay, but exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced
End-Stage Renal Disease (needing dialysis and/or kidney transplant) Doing supervised, moderate aerobic PA undertaken during dialysis sessions may be beneficial and increase compliance

 

Exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced; electrolytes should be monitored when activity done during dialysis sessions
Orthopedic Limitations
Structural Changes to Joints More prone to structural changes to joints that can limit movement, including shoulder adhesive capsulitis, carpal tunnel syndrome, metatarsal fractures, and neuropathy-related joint disorders (Charcot foot)

 

In addition to engaging in other activities (as able), do regular flexibility training to maintain greater joint range of motion; stretch within warm-ups or after an activity to increase joint range of motion best; strengthen muscles around affected joints with resistance training; avoid activities that increase plantar pressures with Charcot foot changes
Arthritis Common in lower extremity joints, particularly in older adults who are overweight or obese; participation in regular physical activity is possible and should be encouraged; moderate activity may improve joint symptoms and alleviate pain Most low- and moderate-intensity activities okay, but more non-weight-bearing or low- impact exercise may be undertaken to reduce stress on joints; do range of motion activities and light resistance exercise to increase strength of muscles surrounding affected joints; avoid activities with high risk of joint trauma, such as contact sports and ones with rapid directional changes

                                                                                                                                                            

Reference cited:

  1. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF: Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2065-2079. http://care.diabetesjournals.org/content/39/11/2065

Is Sitting the New Smoking?

Sitting

Make no mistake: sitting less time overall is a good idea for myriad health reasons, but is sitting as bad for you as some would suggest? Is it really the new smoking? In 2017 alone, a slew of new research studies has looked at various health detriments associated with prolonged sitting, even in adults who exercise regularly.

For adults with type 2 diabetes, bouts of either light walking or simple resistance activities benefit not only their glycemic responses to meals (1; 2), but also markers of cardiovascular risk. Both types of interrupting activities are associated with reductions in inflammatory lipids, increases in antioxidant capacity of other lipids, and changes in platelet activation (3).

What is good for one may not be as beneficial for all, though. For example, in adults with low levels of frailty, sedentary time is not predictive of mortality, regardless of physical activity level (4). Sitting more if you are already frail likely just increases frailty and mortality risk, which is not surprising. Along the same lines, being less fit matters in how you respond to breaking up sedentary time. Middle-aged adults with low levels of cardiorespiratory fitness gained the most metabolic benefit from breaking prolonged sitting with regular bouts of light walking, which included five minutes of light walking every 30 minutes over a 7-hour research period (5). If you’re already very fit, adding in some light walking breaks during the day is not going to have as much of an effect—again not surprising.

For in adolescents in school, reducing their sitting time (both in total time and length of bouts) has been shown to improve their blood lipid profiles and cognitive function. A “typical” day (65% of the time spent sitting with two sitting bouts >20 minutes) was compared with a simulated “reduced sitting” day (sitting 50% less with no bouts >20 minutes (6). Can teens stand to improve their health this week? Again, it cannot hurt to break up sedentary time, so why not do it? More recess breaks for teens would be good—and for everyone else for that matter.

All is not lost for people with limited mobility or no ability to engage in weight-bearing activities. Including short bouts of arm ergometry (five minutes of upper body work only every 30 minutes) during prolonged sitting attenuates postprandial glycemia (following two separate meals) when done by obese individuals at high risk of developing type 2 diabetes, even though they remain seated (7). People who cannot walk or stand can, therefore, break up their sedentary time in other ways that can also be metabolically beneficial.

As for other health benefits, breaking up sedentary time is associated with a lower risk of certain types of cancer. In a recent meta-analysis, prolonged television viewing, occupational sitting time, and total sitting time were all associated with increased risks of colorectal cancer in adults (8), which is the most common type after breast/prostate and lung cancers. That study reported a dose-response effect as well, suggesting that both prolonged total sitting time and greater total daily sitting time (2 hours) were associated with a significantly higher risk of colorectal cancer.

In summary, even just the most recent evidence is convincing enough that prolonged sitting is bad for you, and many more studies published similar results in prior years. Is sitting as bad as smoking, though? That remains to be proven. However, you really cannot argue with a recent international consensus statement on sedentary time in older people (9). It states, “Sedentary time is a modifiable determinant of poor health, and in older adults, reducing sedentary time may be an important first step in adopting and maintaining a more active lifestyle.” In fact, the best advice may simply be to consider the whole spectrum of physical activity, from sedentary behavior through to structured exercise (10). Putting yourself anywhere onto that spectrum is definitely better than sitting through the rest of your (shortened) life.

                                                                                                                                                            References cited:

 

  1. Larsen RN, Dempsey PC, Dillon F, Grace M, Kingwell BA, Owen N, Dunstan DW: Does the type of activity “break” from prolonged sitting differentially impact on postprandial blood glucose reductions? An exploratory analysis. Appl Physiol Nutr Metab 2017;42:897-900. doi: 810.1139/apnm-2016-0642. Epub 2017 Mar 1124.
  2. Dempsey PC, Larsen RN, Sethi P, Sacre JW, Straznicky NE, Cohen ND, Cerin E, Lambert GW, Owen N, Kingwell BA, Dunstan DW: Benefits for type 2 diabetes of interrupting prolonged sitting with brief bouts of light walking or simple resistance activities. Diabetes Care 2016;39:964-972
  3. Grace MS, Dempsey PC, Sethi P, Mundra PA, Mellett NA, Weir JM, Owen N, Dunstan DW, Meikle PJ, Kingwell BA: Breaking Up Prolonged Sitting Alters the Postprandial Plasma Lipidomic Profile of Adults With Type 2 Diabetes. J Clin Endocrinol Metab 2017;102:1991-1999. doi: 1910.1210/jc.2016-3926.
  4. Theou O, Blodgett JM, Godin J, Rockwood K: Association between sedentary time and mortality across levels of frailty. CMAJ 2017;189:E1056-E1064. doi: 1010.1503/cmaj.161034.
  5. McCarthy M, Edwardson CL, Davies MJ, Henson J, Bodicoat DH, Khunti K, Dunstan DW, King JA, Yates T: Fitness Moderates Glycemic Responses to Sitting and Light Activity Breaks. Med Sci Sports Exerc 2017;8:0000000000001338
  6. Penning A, Okely AD, Trost SG, Salmon J, Cliff DP, Batterham M, Howard S, Parrish AM: Acute effects of reducing sitting time in adolescents: a randomized cross-over study. BMC Public Health 2017;17:657. doi: 610.1186/s12889-12017-14660-12886.
  7. McCarthy M, Edwardson CL, Davies MJ, Henson J, Rowlands A, King JA, Bodicoat DH, Khunti K, Yates T: Breaking up sedentary time with seated upper body activity can regulate metabolic health in obese high-risk adults: A randomized crossover trial. Diabetes Obes Metab 2017;23:13016
  8. Ma P, Yao Y, Sun W, Dai S, Zhou C: Daily sedentary time and its association with risk for colorectal cancer in adults: A dose-response meta-analysis of prospective cohort studies. Medicine (Baltimore) 2017;96:e7049. doi: 7010.1097/MD.0000000000007049.
  9. Dogra S, Ashe MC, Biddle SJH, Brown WJ, Buman MP, Chastin S, Gardiner PA, Inoue S, Jefferis BJ, Oka K, Owen N, Sardinha LB, Skelton DA, Sugiyama T, Copeland JL: Sedentary time in older men and women: an international consensus statement and research priorities. Br J Sports Med 2017;19:2016-097209
  10. Dempsey PC, Grace MS, Dunstan DW: Adding exercise or subtracting sitting time for glycaemic control: where do we stand? Diabetologia 2017;60:390-394. doi: 310.1007/s00125-00016-04180-00124. Epub 02016 Dec 00112.

…And Stay Active: My Profile of Success

Sheri exercising pulldown closerI would like to share some of my personal story about why physical activity matters to me and how I have lived successfully with type 1 diabetes for almost 50 years to date. My success with diabetes is undoubtedly related to my decision to be physically active.
The secret to my overall success, both professional and personal, is that I made a conscious choice to live my life by one guiding principle: Live life first, and be diabetic second. In the beginning, I’m not sure it was even a conscious choice (I was only four years old when diagnosed with type 1 diabetes), but rather just an integral part of my personality. I am not one to let obstacles keep me from reaching my goals. Having diabetes has undeniably been one of the greatest challenges to living my life the way I want to, but it has almost never been an insurmountable one.
It’s hard to even imagine life without diabetes when you get it as young as I did. I don’t remember much about being diagnosed other than feeling sluggish and tired all the time. The biggest irony was that my mother had avoided becoming a nurse because she hated needles, but the doctors wouldn’t let me out of the hospital before she learned how to give me shots. She apparently practiced for days shooting water from a syringe into an orange all week. When she gave me my first shot in my arm, she jabbed the needle so hard it rebounded back out. I am told I said, with tears streaming down my face, “Mommy, go practice on the orange some more.”
Diabetes has, in many ways, been a blessing in disguise. It likely had a positive impact on my family’s overall health because our whole family switched to the same diet that was prescribed for me at the time—a balanced diet of carbs, protein, and fat with lots of vegetables, some fruit, and very limited intake of sweets and refined foods. Having diabetes has also been a positive, shaping force in my life when it comes to exercise and physical activity. As such, I have amended my original guiding principle to include, “…and stay active” for that reason: Live life first, be diabetic second, and stay active.
While many people view exercise as a punishment, I fully embrace using diabetes as an excuse to put my workouts first! I started exercising regularly way before it was trendy and known to be good for your health (and blood glucose). I was always active as a kid, playing in the woods, building forts, and just being a tomboy. As a preteen, I began exercising regularly on my own and doing organized sports because being active was the only thing that made me to feel like I had any control over my blood glucose. Way back then no one had blood glucose meters (only inaccurate urine testing), but I could tell being active helped with my blood glucose.
To this day, I still exercise six to seven days a week, and my passion is helping others with all types of diabetes do the same—safely, effectively, and for a lifetime. I vary my daily workouts to keep them fun and to stay injury-free and advise everyone else how to do so. When people ask me how I manage to do all I do, I tell them simply, “I work out.”
Diabetes also led me to an early calling as a healthy lifestyle and diabetes motion expert. When I was about twelve, I spent a week in Kansas with my grandmother, who had what they called “borderline” type 2 diabetes. She was on yet another diet to lose weight, and I decided to help her with dieting while I was there—acting like a personal trainer or fitness coach. I weighed her in every morning, helped her measure out her food (like cottage cheese), and made her jog laps around her backyard. At the start of the week, she agreed to pay me $1 for every pound she lost with my help. She lost eight pounds that week—was I ever a rich kid! Little did I know back then that she likely lost a whole lot less after the first week and gained it all back over time. I just remember her always being about the same body size and shape every time I saw her.
Back then my grandmother was the only other person I knew with diabetes. Later when I was in graduate school working on a degree in exercise physiology, she starting suffering from myriad complications including a heart attack, followed two years later by a major stroke and smaller ones that eventually left her incapacitated. She was bedbound and unable to communicate or feed herself for most her last six years, and she had partial amputations of both of her legs due to chronic ulcers. During one visit, I looked at her and thought, I don’t want to live like that. Consequently, most of my life and career I have focused on how to stay healthy with diabetes and avoid complications. To me, what’s most important is living well while you are alive. That’s why I preach about how important a healthy lifestyle is to maintaining your quality of life (whether you have diabetes or not) and that just living a long time without good health should not be your goal.
You certainly don’t have to get a PhD in exercise physiology like I did to understand the metabolic changes that occur with exercise, but learning why it is so beneficial can be very motivating. You can virtually “erase” overeating mistakes with exercise, and you can keep yourself from getting other health conditions (like heart disease). I’m sure that I am only in excellent health after almost 50 years with type 1 diabetes because of my lifestyle choices—and I want to stay that way until I reach my last day.
As I always say, “What’s the point of living longer if you can’t live well and feel your best every day of your life?” Take my advice and live life first, be diabetic second, and stay as active as you possibly can every day of your healthy (and hopefully long) life.

Exercise and Statins: Revisited

Exercise and statins 

I chronicled someone with type 1 diabetes whose ability to exercise was compromised by his use of statins. Statins are medications prescribed to lower cholesterol levels or abnormal levels of blood fats, given to lower your risk of heart attack and stroke. Examples include Altoprev, Crestor, Lescol, Lipitor, Livalo, Mevacor, Pravachol, and Zocor.

The updated cholesterol guidelines have led to even more adults with diabetes and prediabetes being put on these medications. For anyone unwilling or unable to change diet and lifestyles sufficiently or with genetically high levels of blood lipids, the experts have claimed that the benefits of statins likely greatly exceed the risks. If those risks include the risk of becoming more inactive, then I vehemently disagree with this claim.

This issue is resurfacing for discussion because of a recent study in JAMA Internal Medicine online. That study examined statin treatment among adults aged 65 to 74 years and 75 years and older when used to prevent heart attacks. The statin in in the study was pravastatin (Pravachol), and the adults already had elevated LDL levels and hypertension in most cases. Interestingly, over a six-year period, taking that statin did not lower the risk of having a coronary heart disease event compared to usual care in these older individuals (some of whom likely had diabetes or prediabetes, although this was not stated).

So, if statins don’t always prevent coronary events and may keep you from being active and naturally lowering your cardiovascular risk with physical activity, why take them at all? It may be that glucose, blood pressure, and cholesterol all need to be aggressively managed to see benefits, but then why not try to do that with exercise and physical activity (which can lower all three)? As I stated before, likely the greatest risk factor for heart disease is physical inactivity, so prescribing statins that make people sedentary is counterproductive. At least have them try another medication to see if it has a lesser negative impact on being active.

We already know that many statins increase the risk of developing type 2 diabetes. A recent meta-analysis of 20 studies just reported an increased risk of new-onset diabetes from 9% to 13% associated with statins in just one year, and this could be an underestimation of the risk of developing type 2 diabetes due to statins. Diabetes is known to be a strong and independent risk factor by itself for cardiovascular disease. Does this make the “cure” for high LDL-cholesterol worse than the condition itself?

As a group of medications, statins are recognized for frequently causing muscle and joint issues. Muscular effects from statin use, such as unexplained muscle pain and weakness, are common and may result from a compromised ability to generate energy. The occurrence of muscular conditions like myalgia, mild myositis, severe myositis, and rhabdomyolysis, although relatively rare, is doubled by diabetes. Others have an increased susceptibility to exercise-induced muscle injury when taking statins. Other symptoms, such as muscle cramps during or after exercise, nocturnal cramping, and general fatigue, generally resolve when people stop taking them. It is also concerning that long-term use of statins negatively impacts the organization of collagen and decreases the biomechanical strength of the tendons, making them more predisposed to ruptures. Statin users experience more spontaneous ruptures of both their biceps and Achilles tendons.

You should talk with your doctors about whether it may be possible to manage your heart disease risk without taking statins long-term for this reason. If you experience any of these symptoms, bring up possibly switching to another cholesterol-lowering drug. A newer one on the market that is not a statin is Repatha and is worth a look if such medications absolutely have to be taken. Instead of blocking LDL production by the liver, Repatha apparently is an injectable antibody that helps the liver clear bad LDL-cholesterol from your blood. While its musculoskeletal effects remain to be determined (if any), it appears that it is unlikely to do more harm than statins. It’s worth considering…

When Do You Need a Checkup First Before Starting Exercise?

BP checkHow do you know if you need to get a checkup or medical clearance before you start any exercise training? You should have regular checkups at least annually with your doctor or another healthcare provider if you have any type of diabetes. This helps you keep on top of any problems that may pop up over time that have nothing to do with being physically active.

However, you probably don’t need to see a doctor before you start doing easy workouts or moderate activities like brisk walking. Requiring anyone with diabetes to get medical clearance before starting any type or intensity of exercise is recommended by the American College of Sports Medicine, but is not recommended by the American Diabetes Association because it sets too big of a barrier to participating in regular activities.

On the other hand, having a checkup before you begin more vigorous workouts is a good idea. It also depends on your age, your general health, and your physical activity level. If you’re already doing intense exercise, it’s not necessary, but it is advised for almost everyone with diabetes who is not already exercising at that level—just to be safe.

If/when you do have a checkup, get your blood pressure, heart rate, and body weight measured. If your doctor recommends that you do an exercise stress test, you’ll have to do walking on a treadmill or riding a stationary bike for around ten minutes. Your checkup may also include lab tests (urinalysis, kidney function testing, serum lipid evaluation, and electrolyte analysis) and screening for any diabetes-related complications (including heart, nerve, eye, and kidney disease). Most complications will not keep you from being active, but you may need to take precautions to exercise safely and effectively in certain cases.

For most people, getting a diagnostic graded exercise test is really going too far. Having one is only recommended by the American Diabetes Association if you’re over 40 and have diabetes; or if you’re over 30, have had diabetes for 10 or more years, smoke, have high blood pressure, have high cholesterol, or have eye or kidney problems related to diabetes. If you’re planning to do vigorous training that gets your heart rate up high, these criteria are relevant. If you’re just planning on doing mild or moderate aerobic activity or resistance training, such extensive (and often expensive) testing is unnecessary if you’re reasonably healthy or already fit and don’t have any symptoms of heart or vessel disease.

If you have any pre-existing health complications, you may need to take extra care to prevent problems during exercise. If your blood glucose has been in check, you’ve already been physically active, and you don’t have any serious diabetic complications, then go ahead and keep doing what you’re doing. If you’re very active, getting an extra checkup before you replace your current exercise regime with another exercise routine is neither necessary nor advised.

You still may need to take certain precautions when you exercise, particularly related to getting low blood glucose during and following the activity, going too high, and getting dehydrated. If you have any concerns, check with your healthcare provider at your next visit to discuss any precautions that may be important for your unique health circumstances when exercising.

Resistance Training When You’re Older or Have Limited Mobility

In addition to aerobic activities, you can greatly improve your blood glucose by doing some resistance, or weight, training. Like so many systems in the body, if you don’t use all your muscle fibers, you lose them over time. Anyone past the age of 25 is slowly losing muscle mass, which decreases how many carbs you can store in your muscles as glycogen. You need to retain as much of your muscle mass as possible—and gain more muscle if you can.

If you’re older or have physical limitations, working on your muscular strength helps prevent loss of muscle mass and bone density. The goal of resistance training is increased muscular fitness, both strength and endurance. Regardless of what you type you choose, engaging in any resistance training is always better than doing none.

What should you do if you’re just starting out? Choose among using resistance bands, free weights, resistance machines, or body weight as resistance (for example, doing planks or lunges). The main difference is the intensity of training. For each workout, try to do at least eight to 10 different resistance exercises (at least six to start) that work your full musculature (upper body, lower body, and core). If nothing else, start with strength training exercises that use your own body weight as resistance (like planks, lunges, or wall or modified knee push-ups). Resistance bands, dumbbells, and household items used as resistance (e.g., full water bottles and soup cans) also all work to do these exercises at home on your own. Most training can be done seated for those with mobility and balance issues.

How often should you train? You should ideally perform resistance training at least 2 nonconsecutive days each week, preferably 3. Working the same muscle groups daily doesn’t allow adequate time for recovery and muscle repair between workouts, but if you want to resistance train more than 3 days per week, you can alternate muscle groups when you train on consecutive days. Doing it as infrequently as one day a week can still be beneficial for muscle mass and insulin action.

How hard should it feel? You can gain or maintain strength by doing anywhere from 3 to 15 repetitions per set on each exercise and 1 to 3 sets, with rest between multiple sets. Generally, working up to doing 8 to 12 repetitions and two to three sets is recommended, although you can get stronger from just doing a single set. Start with an easier weight and more reps, and gradually work up to more resistance and fewer reps. If you have joint limitations or other health complications, complete 1 set of exercises for all major muscle groups, starting with 10 to 15 repetitions and progressing to 15 to 20 repetitions before adding extra sets. Your muscles should be working hard during the last 3 to 4 reps in each set, regardless. If it feels too easy, try a heavier resistance or weight; if you can’t complete your goal number of repetitions, try using a lighter amount.

What else do you need to do? Make sure to warm up your muscles and joints before starting resistance training. The best way to warm up if not also doing an aerobic workout is to go through the same motions that used for the workout, but without any resistance. Take time to have them stretch any muscles that feel tight during workouts, since that will help with increasing both flexibility and strength.

How can you avoid getting injured? To avoid injury or work around your existing joint limitations, progress slowly toward working out harder or more frequently. It’s generally better to increase your weight or resistance first—only the number of reps you’re doing is way too easy—and only then increase your number of sets and lastly add in additional training days. Expect that is should take you six months or more to progress up to doing 3 days per week (and only if you want to) and doing up to 3 set of 8 to 10 reps each—an optimal goal for most adults with diabetes.

Resistance Training Goals, Recommendations, and Precautions:

  • Short-term goal: 1 to 2 times per week, 6 to 8 exercises to start
  • Long-term goal: 3 days per week, 10 to 12 exercises
  • 2 to 3 sets per exercise
  • 10 to 15 reps per exercise to start; 8 to 12 reps per exercise later on
  • Start slowly with training and build up
  • Don’t resistance train the same muscle groups more often than every other day
  • Gradually increase resistance or weights over time
  • Perform exercises with slow controlled movements
  • Extend limbs and use the full range of motion around each joint being worked
  • Breathe out during exertion, and always avoid breath holding
  • Stop exercise if dizziness, unusual shortness of breath, chest discomfort, palpitations, or joint pain occurs