Category Archives: Hypoglycemia

Losing Weight with Diabetes: What Prevents It and Causes Weight Gain

Scale weight 2Last year I was included in a discussion on a Facebook group for athletes with diabetes about how hard it can be to lose weight through exercise. While I don’t have all the answers on this topic, here are some ideas about what can make you gain weight or keep you from losing weight with diabetes, based on my decades of professional and personal experience with diabetes and weight management, and what you can do about it.

Insulin: My former graduate student with type 1 diabetes went on an insulin pump and promptly gained about 10 pounds, even though his blood glucose control improved only marginally. Why does it happen to so many insulin users? As an anabolic hormone, insulin promotes the uptake and storage of glucose, amino acids, and fat into insulin-sensitive cells around your body (mainly muscle and fat cells). It doesn’t matter whether it’s released naturally, injected, or pumped. Going on insulin therapy is associated with fat weight gain (1), for people with both type 1 and type 2 diabetes. When you lower blood glucose with insulin, you keep and store all of the calories instead of losing some glucose through urine (during hyperglycemia). Unfortunately, some people skip or limit their insulin use to help them lose weight (2), but that is a dangerous practice that can lead to loss of excess muscle mass and life-threatening conditions like DKA. The best way to balance your insulin use and your body weight, in my opinion, is to be physically active to keep your overall insulin levels lower. It’s easier to lose weight, too, when you’re taking less insulin—or releasing less of your own if your pancreas still does that.

Food Choices: What you choose to eat has a huge impact on your insulin needs as well as your body weight. My graduate student found that by doing frequent dosing with his insulin pump, he was eating more overall because he could without having to take another injection with a needle. Just because insulin use can make it easier for you to eat cake and other formerly “forbidden” foods doesn’t mean that you need to eat them! There are advocates out there for all sorts of diets for people with diabetes, including ultra-low-carb ones (like Dr. Bernstein’s), vegan ones, etc. Personally, what I have always founds works best is a balanced diet. People don’t necessarily lose weight on low-carb diets, even though their insulin requirements are lower because fat is so much denser in calories (at over 9 calories/gram of fat) than carbs or protein (both 4 calories per gram). If you cut carbs out of your diet, you have to eat something in its place. It’s just too easy to overdose on fat calories without realizing it, and even when your muscles become insulin resistant for any reason, insulin still works to put fat into storage depots around the body. Don’t completely avoid carbs; rather, choose them wisely—eating more carbs that are absorbed more slowly and don’t cause spikes in blood glucose that you have to try to match with large doses of insulin that often lead to hypoglycemia later. Most carbs are fully absorbed in the first hour or two after you eat them, and even rapid-acting insulin can linger for up to 8 hours afterwards. Besides, insulin requirements are determined by more than just carbs, and eating fat with the same number of carbs increases insulin requirements (3). It’s not just about carb counting anymore (and never has been for me); it’s about picking the right balance and type of carbs, as well as total amounts of protein (good for preventing lows 3 to 4 hours later) and fat (fully absorbed in 5 to 6 hours, causing insulin resistance).

Treating Lows: I was contacted once by a US Olympic team handball player with type 1 diabetes who wanted to ask me why she was gaining fat weight while doing all her training. My first question to her was, “Are you treating a lot of lows?” I knew she was going to answer yes. Gaining weight from treating lows is common in people using insulin, whether they are active or not. One of the biggest deterrents to successful weight loss and prevention of weight gain with diabetes is being forced to treat frequent bouts of hypoglycemia with glucose, sugary drinks, or food. Even though these calories are necessary to treat a medical condition, they still count as calories in the body. One way to cut back on lows is to decrease your insulin intake to prevent them, which may include decreasing meal-time insulin doses before exercise, insulin taken for food after exercise, and basal insulin doses to prevent later-onset hypoglycemia following activities. It also helps to more precisely treat lows instead of overtreating them (it’s harder to follow this advice when you’re low, though!) Immediately treat lows first with glucose—in the form of tablets, gels, or candy containing dextrose like Smarties—and then reassess later if you need additional food intake (often a mix of carbs, protein, and fat) to fully correct the low and prevent lows later on. Juice, although often touted as a treatment for hypoglycemia, contains fructose (fruit sugar) that is much, much more slowly absorbed than glucose and can lead to overtreating lows while you’re waiting for the juice to kick in. Don’t eat more calories treating a low than you need to!

Lack of Physical Movement: Finally, and I probably should have listed this section first, expending more calories can help prevent weight gain, even if you take insulin. In adults with type 1 diabetes, having an active lifestyle compared with a more sedentary one has been associated with a lower BMI (body mass index) and percentage of total and truncal fat mass (5). The more you move, the less insulin your body needs to get the same glucose-lowering effect. Requiring smaller doses of insulin allows you to 1) treat lows with fewer calories overall, and 2) avoid having as many lows from being off on your dosing. In anyone who is insulin resistant (most people with type 2 diabetes and many with type 1 who are inactive), total insulin requirements will be so much higher that there is a lot more room for error. Injected or pumped insulin is generally absorbed at a speed dictated by the dose, meaning that larger doses take longer to fully absorb and the insulin “tail” hangs around for longer. Taking or releasing less insulin due to being physically active means that all of the carbs you take will be stored as carbs in muscle or liver and not converted into fat to be stored. Stay regularly active—even if that means just standing up more or taking more daily steps–to keep your calorie expenditure high and your insulin needs low.


(1) Conway B, Miller RG, Costacou T, Fried L, Kelsey S, Evans RW, and Orchard TJ. Temporal patterns in overweight and obesity in Type 1 diabetes. Diabet Med 27: 398-404, 2010. (

(2) Ackard DM, Vik N, Neumark-Sztainer D, Schmitz KH, Hannan P, and Jacobs DR, Jr. Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatr Diabetes 9: 312-319, 2008. (

(3) Wolpert HA, Atakov-Castillo A, Smith SA, and Steil GM. Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes care 36: 810-816, 2013. (

(4) Brown RJ, Wijewickrama RC, Harlan DM, and Rother KI. Uncoupling intensive insulin therapy from weight gain and hypoglycemia in type 1 diabetes. Diabetes Technol Ther 13: 457-460, 2011. (

(5) Brazeau AS, Leroux C, Mircescu H, and Rabasa-Lhoret R. Physical activity level and body composition among adults with type 1 diabetes. Diabet Med 29: e402-408, 2012. doi: 410.1111/j.1464-5491.2012.03757.x. (

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.


(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.

How to Treat Lows–as Quickly as Possible

Glucose pictureYou have to love it when research studies come out and prove what you believed all along. I had this experience recently when a systematic review and meta-analysis (looking at the results from multiple studies simultaneously) e-published ahead of print in Emergency Medicine Journal in September 2016 (1) compared the speed of glucose tablets against dietary sugars for treating hypoglycemia in adults who had symptoms of being low. The dietary forms of sugar tested included sucrose (table sugar), fructose (fruit sugar), orange juice (containing fructose), jelly beans, Mentos, cornstarch hydrolysate, Skittles, and milk.

What the compiled data from four studies suggested is that “when compared with dietary sugars, glucose tablets result in a higher rate of relief of symptomatic hypoglycemia 15 min after ingestion and should be considered first, if available, when treating symptomatic hypoglycemia in awake patients.” In other words, glucose worked faster in resolving symptoms of feeling low—and who wouldn’t want to feel low for less long?

Why does glucose work faster? It’s because glucose is the actual sugar in blood that you’re trying to raise. There are three simple sugars in our diet: glucose, fructose, and galactose. Sucrose (table sugar) is a compound sugar that is only half glucose, half fructose. As shown by its glycemic index, fructose raises blood glucose much more slowly than glucose, likely because fructose has to be converted into glucose. For this reason, juice is not an ideal treatment for hypoglycemia, and it’s very easy to consume too much of it. Milk can also act more slowly (especially if it has any fat in it) because lactose (milk sugar) is half glucose and half galactose.

Others say that other treatment options work better and faster for them than glucose. That’s not surprising since even this meta-analysis found that neither glucose nor dietary sugars reliably raised blood glucose levels to normal within 10 to 15 minutes. Since lows occur for all sorts of reasons—including missing a meal, exercising, overestimating insulin needs, and more—how you best treat it depends on a number of factors, and not all treatments are going to work the same in every situation. The rate at which your blood glucose reaches hypoglycemic levels will also vary, as will how low it goes and how long it will continue to drop.

If you have some glucose handy, though, the fastest way to initially bring up your blood glucose is likely by consuming some straight glucose, which you can get in glucose tablets and gels, Gu (maltodextrin), Gatorade and other sports drinks (glucose polymers), and even Smarties candy (dextrose, another name for glucose). You may have to follow glucose intake with more glucose, another carb snack, mixed nutrient snack (with some fat and protein), or a full meal, depending on why you went low in the first place.

To treat hypoglycemia, focus on doing three things: (1) raising your blood glucose out of the low range as quickly as possible, (2) not overtreating a low, and (3) not taking in any more calories than necessary. For these reasons I recommend using at least a small amount of glucose to initially relieve your immediate symptoms and then deciding—based on when you last ate, what you ate, how much insulin you’ve had, activity levels, etc.—if you need to follow up that up with anything else to fully resolve the low, prevent it from recurring, and not overshoot your blood glucose target.

Honestly, there’s nothing worse than feeling low for a long time, except for maybe ending up high later after you’ve eaten everything in sight. You also don’t want to gain excess fat weight from having to treat too many lows or from overtreating them (requiring more insulin later to bring down highs). Treat them with as few calories as possible for all these reasons! Be prepared and always carry some glucose with you, along with other snacks.


(1) Carlson JN, Schunder-Tatzber S, Neilson CJ, Hood N. Dietary sugars versus glucose tablets for first-aid treatment of symptomatic hypoglycaemia in awake patients with diabetes: a systematic review and meta-analysis. Emerg Med J. 2016 Sep 19. doi: 10.1136/emermed-2015-205637. [Epub ahead of print]