Category Archives: Exercise with Complications

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

Staying Active with Aging Joints and Diabetes

Using bandsWithout properly functioning joints, our bodies would be unable to bend, flex, or even move. A joint is wherever two bones come together, held in place by tendons that cross the joint and attach muscles to a bone on the other side and ligaments that attach to bones on both sides of the joint to stabilize it. The ends of the bones are covered with cartilage, a white substance. Specialized cells there called chondrocytes produce large amounts of an extracellular matrix composed of collagen fibers, proteoglycan, elastin fibers, and water. Tendons and ligaments are also made up of primarily of collagen.

Joints can be damaged, however, making movement more difficult or painful. Joint cartilage can be damaged by acute injuries (i.e., ankle sprain, tendon or ligament tears) or overuse (related to repetition of joint movements and wear-and-tear over time). Damage to the thin cartilage layer covering the ends of the bones is not repaired by the body easily or well, mainly because cartilage lacks its own blood supply.

Aging alone can cause you to lose some loss of this articular cartilage layer in knee, hip, and other joints—leading to osteoarthritis and joint pain—but having diabetes also potentially speeds up damage to joints. Although everyone gets stiffer joints with aging, diabetes accelerates the usual loss of flexibility by changing the structure of collagen in the joints, tendons, and ligaments. In short, glucose “sticking” to joint surfaces and collagen makes people with diabetes more prone to overuse injuries like tendinitis and frozen shoulder (1; 2). It may also take longer for their joint injuries to heal properly, especially if blood glucose levels are not managed effectively. What’s more, having reduced motion around joints increases the likelihood of injuries, falls, and self-imposed physical inactivity due to fear of falling.

Reduced flexibility limits movement around joints, increases the likelihood of orthopedic injuries, and presents a greater risk of joint-related problems often associated with diabetes, such as diabetic frozen shoulder, tendinitis, trigger finger, and carpal tunnel syndrome. These joint issues can come on with no warning and for no apparent reason, even if an individual exercises regularly and moderately, and they may recur more easily as well (3). It is not always just due to diabetes, though, since older adults without diabetes experience inflamed joints more readily than when they were younger.

So what can you do to keep your joints mobile if you’re aging (as we all are) and have diabetes? Regular stretching to keep full motion around joints can help prevent some of these problems, and also include specific resistance exercises that strengthen the muscles surrounding affected joints. Vary activities to stress joints differently each day. Overuse injuries occur following excessive use the same joints and muscle in a similar way over an extended period of weeks or months, or they can result from doing too much too soon.

Doing moderate aerobic activity that is weight-bearing (like walking) will actually improve arthritis pain in hips and knees (4). People can also try non-weight-bearing activities, such as aquatic activities that allow joints to be moved more fluidly. Swimming and aquatic classes (like water aerobics) in either shallow or deep water are both appropriate and challenging activities to improve joint mobility, overall strength, and aerobic fitness. Walking in a pool (with or without a flotation belt around the waist), recumbent stationary cycling, upper-body exercises, seated aerobic workouts, and resistance activities will give you additional options to try.

Finally, managing blood glucose levels effectively is also important to limit changed to collagen structures related to hyperglycemia. Losing excess weight and keeping body weight lower will decrease the risk for excessive stress on joints that can lead to lower body joint osteoarthritis (5). Simply staying as active as possible is also critical to allowing your joints to age well, but remember to rest inflamed joints properly to give them a chance to heal properly. You may have to try some new activities as you age to work around your joint limitations, but a side benefit is that you may find some of them to be enjoyable!

References:

  1. Abate M, Schiavone C, Pelotti P, Salini V: Limited joint mobility in diabetes and ageing: Recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2011;23:997-1003
  2. Ranger TA, Wong AM, Cook JL, Gaida JE: Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med 2015;
  3. Rozental TD, Zurakowski D, Blazar PE: Trigger finger: Prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am 2008;90:1665-1672
  4. Rogers LQ, Macera CA, Hootman JM, Ainsworth BE, Blairi SN: The association between joint stress from physical activity and self-reported osteoarthritis: An analysis of the Cooper Clinic data. Osteoarthritis Cartilage 2002;10:617-622
  5. Magrans-Courtney T, Wilborn C, Rasmussen C, Ferreira M, Greenwood L, Campbell B, Kerksick CM, Nassar E, Li R, Iosia M, Cooke M, Dugan K, Willoughby D, Soliah L, Kreider RB: Effects of diet type and supplementation of glucosamine, chondroitin, and msm on body composition, functional status, and markers of health in women with knee osteoarthritis initiating a resistance-based exercise and weight loss program. J Int Soc Sports Nutr 2011;8:8

Physical Activity/Exercise and Diabetes (ADA 2016 Position Statement)

ADA Position Statement CoverI would like to let everyone know about a new position statement that covers all types of diabetes (type 1, type 2, and gestational) and prediabetes and addresses physical activity and exercise. It is based on an extensive review of more than 180 papers covering the latest diabetes research and includes the expertise of leaders in the field of diabetes and exercise from top research institutions in the US, Canada, and Australia.

The most notable recommendation calls for three or more minutes of light activity, such as walking, leg extensions or overhead arm stretches, every 30 minutes during prolonged sedentary activities for improved blood sugar management, particularly for people with type 2 diabetes. Sedentary behavior—awake time that involves prolonged sitting, such as sitting at a desk on the computer, sitting in a meeting or watching TV—has a negative effect on preventing or managing health problems, including diabetes. Studies have shown improved blood sugar management when prolonged sitting is interrupted every 30 minutes—with three minutes or more of standing or light-intensity activities, such as leg lifts or extensions, overhead arm stretches, desk chair swivels, torso twists, side lunges, and walking in place. Physical movement improves blood sugar management in people who have sedentary jobs and in people who are overweight, obese and who have difficulty maintaining blood sugars in a healthy range.

These updated guidelines are intended to ensure everyone continues to physically move around throughout the day – at least every 30 minutes – to improve blood glucose management. This movement should be in addition to regular exercise, as it is highly recommended for people with diabetes to be active.

Since incorporating more daily physical activity can mean different things to different people with diabetes, these guidelines offer excellent suggestions on what to do, why to do it and how to do it safely. It includes various categories of physical activity—aerobic exercise, resistance training, flexibility and balance training, and general lifestyle activity—and the benefits of each for people with diabetes.

Aerobic activity benefits patients with type 2 diabetes by improving blood sugar management, as well as encouraging weight loss and reducing cardiovascular risks. Movement that encourages flexibility and balance are helpful for people with type 2 diabetes, especially older adults. Regular aerobic and resistance training also offer health benefits for people with type 1 diabetes, including improvements in insulin sensitivity, cardiovascular fitness and muscle strength. Women who are at-risk or diagnosed with gestational diabetes are encouraged to incorporate aerobic and resistance exercise into their lives most days of the week. People with prediabetes are urged to combine physical activity and healthy lifestyle changes to delay or prevent a type 2 diabetes diagnosis.

Recommendations and precautions for physical activity and exercise will vary based on a patient’s type of diabetes, age, overall health and the presence of diabetes-related complications. Additionally, specific guidelines are outlined on monitoring blood sugar levels during activity. The statement also suggests positive behavior-change strategies that clinicians can utilize to promote physical activity programs.

Reference:

(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, 39(11): 2065-2079, 2016. http://dx.doi.org/10.2337/dc16-1728

What You Don’t Know about Statins Can Hurt You

Muscle massage

I recently received an email from a person with type 1 diabetes living in Denmark (Guido) whose physician believes in prescribing many medications to manage cholesterol and high blood pressure in anyone with diabetes, regardless of need. Guido has been taking a statin (Atorvastatin, brand name Lipitor), along with at least four others for blood pressure control. He used to take Simvastitin (Zocor), but a year prior had been changed to Atorvastatin (and his dose doubled). That’s when his problems with exercise began.

Statins are taken to treat high cholesterol levels or abnormal levels of blood fats, in an attempt to lower the risk of heart attack and stroke. Brand name examples include Altoprev, Crestor, Lescol, Lipitor, Livalo, Mevacor, Pravachol, and Zocor.

The cholesterol guidelines were recently updated, so now even more adults with diabetes and prediabetes are being prescribed these medications. In individuals who are unwilling or unable to change their diet and lifestyles sufficiently or have genetically high levels of blood lipids, the benefits of statins for lowering cardiovascular risk likely greatly exceed the risks, or so the experts claim (1). If a person has a low risk for developing cardiovascular problems and does not already have type 2 diabetes, taking them is not advised (2), particularly because many statins increase the risk of developing type 2 diabetes (3).

Since one month after he started taking Atorvastatin, Guido confided that has been suffering from extreme stiffness and pain in his legs that occurs after running any distance (3 km or 20 km). The pain is in his lower leg/ankle (the right one hurts more, but the left leg is also very stiff) and occurs typically after his runs and decreases after 3 to 4 days, during which time he is unable to run at all. His legs have been scanned and are negative for any signs of fractures or inflammation, and they have ruled out compartment syndrome.

In his email, Guido stated: “I suspect it is the Atorvastitin. What do you think?”

My answer was, “I completely agree that your problems are probably coming from the Atorvastatin. As a group of medications, the statins are WELL known for causing muscle and joint issues.  I would suggest considering going off of it completely and see if your symptoms resolve in a few weeks.”

Guess what?  It worked!  He emailed me a week later, stating “I have stopped using the Statins now for 5 days and after a 12 km run my legs feel completely different and back to normal.” That was great news to hear!

Undesirable muscular effects from statin use are commonplace, such as unexplained muscle pain and weakness with physical activity that Guido has been having, which may be related to statins compromising the ability of the muscles to generate energy. The occurrence of muscular conditions like myalgia and rhabdomyolysis, although rare, is doubled with diabetes (4). Others have reported an increased susceptibility to exercise-induced muscle injury when taking statins, particularly active, older individuals (5). Other symptoms, such as muscle cramps during or after exercise, nocturnal cramping, and general fatigue, generally resolve when people stop taking them. If you experience any of these symptoms, you need to talk with your health care provider about switching to another cholesterol-lowering drug that may not cause them.

Long-term use of statins also 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 (6-8); I personally know a physically active person with type 1 diabetes that simultaneously ruptured both of his Achilles tendons during a routine workout due to long-term statin use. Again, talk with your doctor about whether it may be possible to manage your heart disease risk and lipid levels without taking statins long-term for all these reasons.

There’s nothing worse than a medication that is supposed to help lower your cardiovascular risk, but ends up removing all of the potential benefits by taking away your ability to be active! Likely the greatest risk factor for heart disease is physical inactivity, so don’t take statins if they make you sit on the couch. At least try another medication to see if it has a lesser negative impact on being active.

References cited:

  1. Kones R: Rosuvastatin, inflammation, C-reactive protein, JUPITER, and primary prevention of cardiovascular disease–a perspective. Drug Des Devel Ther 2010;4:383-413
  2. Taylor F, Ward K, Moore TH, Burke M, Davey Smith G, Casas JP, Ebrahim S: Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2011:CD004816
  3. Mayor S: Statins associated with 46% rise in type 2 diabetes risk, study shows. BMJ 2015;350:h1222
  4. Nichols GA, Koro CE: Does statin therapy initiation increase the risk for myopathy? An observational study of 32,225 diabetic and nondiabetic patients. Clin Ther 2007;29:1761-1770
  5. Parker BA, Augeri AL, Capizzi JA, Ballard KD, Troyanos C, Baggish AL, D’Hemecourt PA, Thompson PD: Effect of statins on creatine kinase levels before and after a marathon run. Am J Cardiol 2012;109:282-287
  6. de Oliveira LP, Vieira CP, Da Re Guerra F, de Almeida Mdos S, Pimentel ER: Statins induce biochemical changes in the Achilles tendon after chronic treatment. Toxicology 2013;311:162-168
  7. de Oliveira LP, Vieira CP, Guerra FD, Almeida MS, Pimentel ER: Structural and biomechanical changes in the Achilles tendon after chronic treatment with statins. Food and chemical toxicology: an international journal published for the British Industrial Biological Research Association 2015;77:50-57
  8. Savvidou C, Moreno R: Spontaneous distal biceps tendon ruptures: are they related to statin administration? Hand surgery: an international journal devoted to hand and upper limb surgery and related research: journal of the Asia-Pacific Federation of Societies for Surgery of the Hand 2012;17:167-171

Don’t Let Diabetes Stand in the Way of Your Dreams

Sheri and Steve at UVI (brighter)

I had to wait more than half my life to overcome the only thing I had never been allowed to do with type 1 diabetes…but I finally prevailed.

You can do almost everything you want to with diabetes.  One blaring exception is scuba diving through any NAUI (National Association of Underwater Instructors) organization.

My story is that when I was a graduate student back in 1987, I signed up at the University of California, Davis for a scuba diving certification course.  I didn’t know about NAUI or much of anything scuba-related, but got a rude awakening when I was booted out of the class after having a required physical exam and admitting that I had type 1 diabetes.  I was devastated.  Despite having had diabetes since the age of four, I had never let it stand in my way of reaching my goals (even though I didn’t have a blood glucose meter back then).

So, I went with the UC Davis scuba class to Lake Tahoe and waited lakeside while everyone else in the class got to dive.  I guess I was just a glutton for punishment!

What I didn’t know at the time was that the other primary scuba diving organization (PADI, the Professional Association of Diving Instructors) lets people with type 1 diabetes dive, and thousands of individuals with diabetes have dived safely over the years.  The Divers Alert Network (DAN) has also advised people with diabetes about staying safe while diving, and many of their recommendations are based on the extensive experience with diving with adults with type 1 diabetes amassed by Steve Prosterman, a diving instructor at the University of the Virgin Islands (who also happens to have type 1 diabetes).

I met Steve at a diabetic athletes’ meeting I attended back in 1990, and after hearing my story, he graciously invited me to come to UVI anytime to learn how to dive with him.  I waited 27 years to take him up on his offer, but I finally fulfilled my almost lifelong dream of going scuba diving–on my 50th birthday!  It was the best way I could have ever celebrated a half-century of life and almost 46 years living with type 1 diabetes.  Thank you, Steve, for helping me make my dream come true!

Sheri, 1; type 1 diabetes and NAUI, 0. Finally!!