Category Archives: Medications

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 found 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 afterward. 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.

References:

(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. (http://www.ncbi.nlm.nih.gov/pubmed/20536510)

(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. (http://www.ncbi.nlm.nih.gov/pubmed/18466215)

(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. (http://www.ncbi.nlm.nih.gov/pubmed/23193216)

(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. (http://www.ncbi.nlm.nih.gov/pubmed/21355723)

(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. (http://www.ncbi.nlm.nih.gov/pubmed/22817453)

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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

Head Scratching Days with Insulin Action Changes

SB sprint subject (and Sheri)

The topic of insulin action (resistance and sensitivity) has come up multiple times over the years in my articles and posts, but it is admittedly much more complex than I often make it out to be. In a DiabetesInControl article I posted last summer, you can find a short list of all the factors that can potentially improve insulin action (basically insulin sensitivity). In reality, though, sometimes it is impossible to know exactly what is affecting it.

Recently, I spent the majority of two days traveling in a car and not exercising, and I reached the point where I could barely eat anything without my blood glucose rising over 200 mg/dL, even when giving twice or three times my usual insulin dose for the same food. Just sitting in a car and not exercising resulted in full muscle glycogen stores, with no room to store more carbohydrate—hence the resulting muscular insulin resistance. Even I was frustrated by dealing with my lack of immediate control, even though I knew that physical inactivity was the cause.

Based on my personal experience, I want to take some of the burden of always being on top of blood glucose levels off of anyone with diabetes. Sometimes you can do everything right and your insulin action can still less (or more) than expected. It’s not necessarily your fault, nor can you always anticipate how to best combat it.

Here is my short list of factors from my personal experience that can make people insulin resistant one day and insulin sensitive the next—and not always as you would expect. I call those the “head scratching days,” but sometimes it’s more like hair pulling!

  • If you’ve had a prior hypoglycemic event

Going too low and staying there for a while (such as during sleep) may increase insulin resistance more than just having a simple hypo event and treating it quickly. Morning insulin resistance is the most variable anyway (higher levels of cortisol then). It is admittedly my most frustrating time of day since often the same exact breakfast and starting blood glucose level will result in a different rise in blood glucose levels. Sometimes an overnight low explains it, but sometimes it doesn’t.

  • If your blood glucose has been running high

Hyperglycemia begets more hyperglycemia because it causes insulin resistance. That is why sometimes it takes way more insulin than you would expect just to get back to a normal level, and it may take hours. Try not to overdose on insulin in the meantime (especially you’re your bedtime) or you’ll end up low and back on the blood glucose rollercoaster.

  • If you’ve drastically changed your normal exercise patterns

Heightened insulin action due to your last workout is fleeting, and sitting in a car for two days is a dramatic change for me, particularly since my basal and other insulin doses are set for being active, not for being inactive. Even a week of detraining (due to injury, vacation, sickness, or other life event) can cause insulin resistance to rise rapidly in everyone, not just in people with diabetes. If you start working out more overall or just more regularly, your overall insulin needs (including basal) may also decrease. Just try to be as consistent as possible to make it easier for yourself to manage.

  • If you ate more calories, fat, or protein than you realized

Eating out at restaurants is really hard for me because no matter what I order, it seems like it takes two to three times my usual insulin doses to cover it. It is likely because protein and fat kick in and affect blood glucose levels later on (3-6 hours after a meal) and restaurant meals have more calories in them than most home-cooked meals. Fat, sugar, and salt keep people coming back to the restaurant for more! You can strategically use protein and fat intake overnight or after exercise to help prevent later-onset lows, though.

  • If you’re stressed, mentally or physically

It is truly amazing how much of an impact that stress has on blood glucose levels. Just try going to court (if you’re not an attorney) and keep your blood glucose in check while your adrenaline is pumping. Your cortisol levels also go up and raise blood glucose. So, just being stressed out during the day, or being exhausted or sick (physical stress), can cause insulin resistance. Try to take deep breaths and get some exercise during the day to combat both the stress and the resulting insulin resistance. Getting sick and running a fever or having an infection can also drive your blood glucose and insulin needs up.

  • If you’re lacking on sleep

Not getting enough sleep is physically (and often mentally) stressful. I knew an oceanography professor who had to harvest samples at sea, sometimes for days at a time, on no sleep.  The longer he went without sleeping, the higher his insulin resistance became. Lack of sleep may be causing some of your unexplained highs since more cortisol (a stress hormone) is released when you are sleep-deprived.

  • If you’ve had some alcohol to drink

Alcohol interferes with the normal function of the liver in making and releasing glucose. While it can lead to hypos, it can also be used strategically to relieve insulin resistance or to keep it in check—and luckily it does not take much alcohol to have an effect. An older guy called me on a diabetes hotline I was manning for a TV station once and explained that he usually had two shots of whiskey at night and woke up with good blood glucose levels, but that if he ever had to skip the whiskey, he would wake up too high.  He wanted to know what he should do.  I said, “Keep drinking the whiskey!” No more than one drink daily for women or two for men is recommended, though, so do not overdo it or you raise your risk of other health problems.

  • If it’s a certain time of the month (women only)

You may have everything else accounted for and your blood glucose levels are still skyrocketing for apparently no reason—except that you’re either ovulating (and releasing extra hormones that promote insulin resistance) or in the few days or week leading up to your period when insulin resistance is highest.  This has been a bigger issue for me later in life since my cycles seem to be more extreme, although I do not know if this is the case for all women. I helped a diabetes educator recently figure out that she was pregnant when she simply could not figure out why her blood glucose levels were so whacked out; it can be as simple an explanation as that (and hopefully a desired one, if pregnant).

Regardless of what is causing your (unexplained) insulin resistance, just try to manage your blood glucose levels the best you can and lose the guilt over not knowing exactly why it is high and not being totally in control 24/7. Even the most knowledgeable of us have our head-scratching and/or hair-pulling days trying to figure it out!

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

Interactions of Exercise and Medications (for Diabetes or Other Things)

Kayley Wolf testing basketballSome prescribed medications, including some of the oral diabetic medications, can affect your body’s response to exercise. For example, certain sulfonylureas increase your risk of developing hypoglycemia. Older-generation sulfonylureas (such as Diabinese and Orinase) cause insulin release from your pancreas and somewhat decrease your insulin resistance. However, these older medications typically have a longer duration of up to 72 hours, giving them the greatest potential to cause your blood sugars to go too low during and/or after any physical activity. Newer sulfonylureas, such as Amaryl, DiaBeta, Micronase, and Glucotrol, generally don’t last as long and carry a smaller risk of causing hypoglycemia. Of this type, DiaBeta and Micronase carry the greatest risk due to their slightly longer duration (24 hours versus only 12 to 16 hours for the others). You should check your blood sugars more often when exercising if you take any of the sulfonylureas that stay in your system longer. When your exercise becomes regular, you may need to check with your health-care provider about lowering your doses of these medications if you experience more frequent lows.

Other medications may not affect your glycemic response to exercise. Insulin sensitizers like Avandia and Actos mainly affect the action of your insulin at rest, not during exercise, so their risk of causing exercise hypoglycemia is almost nonexistent. Similarly, Glucophage is unlikely to cause exercise lows. Prandin or Starlix use only potentially increases your risk if taken immediately before prolonged exercise since they increase insulin levels in the blood only temporarily when taken with meals. Finally, medications that slow down the absorption of carbohydrates (Precose and Glyset) would not directly affect exercise, but could slightly delay your treatment of a low by slowing the absorption of carbohydrates you eat to treat it.

If you use insulin, you face a potentially more complicated exercise-medication interaction. Understanding the effects of insulin action and different regimens on glycemic control is one of the best strategies for optimizing exercise management. Both insulin and muscular contractions evoke separate mechanisms that cause you to take up glucose into your muscles, and they additively increase muscle glucose uptake. Consequently, the type of insulin that you use and the timing of its use can have a large effect on glycemic responses. You may be one of the many individuals who use a combination of short- and long-acting insulins (varying by time to peak action and total duration) given two to four (or more) times daily, or you may receive a continuous infusion of short-acting insulin through an insulin pump.

When no more than minimal (basal) levels of insulin are circulating in your body during exercise, your blood glucose response will be more normal, more like someone who doesn’t have diabetes. If you exercise when your insulin levels are peaking, however, you’ll have an increased risk of hypoglycemia. For example, if you inject intermediate-acting N at breakfast, it will peak around noon and exert its effects throughout the afternoon; if you exercise then, your blood sugars may drop more rapidly than at other times. If you use only Lantus or Levemir, both provide basal insulin coverage for 24 hours, making a separate dose of short-acting insulin required to cover lunch if your body no longer makes much insulin. Either basal insulin by itself, with no rapid-acting insulin (or if your last injection of rapid-acting insulin has peaked and waned before you start exercising), will result in a lower risk of hypoglycemia. Similarly, insulin pump users can normalize their response to exercise by either disconnecting their pumps or reducing programmed basal rates during physical activity; some users also decrease their basal rates before and/or after the activity, depending on how long it lasts and on their individual blood sugar responses.

Besides taking medications for diabetes control, you may also need help controlling your blood lipids (especially cholesterol levels), hypertension, and other coexisting health problems. Most medications taken for nondiabetic reasons will not affect your exercise response directly–with a few notable exceptions. Certain medications taken to treat high cholesterol levels or abnormal levels of blood fats (i.e., the “statins,” including Lipitor, Mevacor, Pravachol, Crestor, and Zocor) may result in unexplained muscle pain and weakness with physical activity, possibly by compromising your muscles’ ability to generate energy; however, case reports of muscle cramps during or after exercise, nocturnal cramping, and general fatigue show that these symptoms resolve when you discontinue taking the statins. If you are taking a statin and experience any of these symptoms with exercise, talk with your doctor about possibly switching to another type of cholesterol-lowering drug. Moreover, any medications taken to reduce your body water levels (diuretics like Lasix, Microzide, Enduron, and Lozol) and improve your blood pressure can lead to dehydration and dizziness from hypotension (low blood pressure), but will not likely affect your blood sugars. Vasodilators such as nitroglycerin allow more blood to flow to your heart during exercise, but they can also induce low blood pressure, which may cause you to faint during or following an activity. You’ll also experience a dramatic effect with beta-blockers (Lopressor, Inderal, Levatol, Corgard, Tenormin, Zebeta, and others) taken to treat heart disease and hypertension, as they lower both your resting and exercise heart rates; if you are taking a blocker, your heart rate will not reach any age-expected value at any intensity of exercise.

Kayley Wolf testing basketballOn the other hand, if you are taking either ACE inhibitors (Capoten, Accupril, Vasotec, Lotensin, Zestril, etc.) or angiotensin II receptor blockers (ARBs, such as Cozaar, Benicar, and Avapro) to reduce your blood pressure and/or protect your kidneys from possible damage, you should expect no negative effects during exercise. In fact, using certain ACE inhibitors may lower your risk of untoward cardiovascular events if you have heart disease. Other medications taken to treat heart disease and hypertension (calcium-channel blockers like Procardia, Sular, Cardene, Cardizem, and Norvasc),depression (Wellbutrin, Prozac, and others), or chronic pain (Celebrex) will have no effect on your ability to exercise safely and effectively. Keep in mind, though, that aspirin and other blood thinners (such as Coumadin) have the potential to make you bruise more easily or extensively in response to athletic injuries.

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

Last year I participated in a discussion on a Facebook group for athletes with diabetes about how hard it can be to lose weight through exercise. While I would never claim to 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. wirchappybiker

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 did this happen to him (and why does it happen to so many other insulin users)?

As a naturally occurring 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—all insulin and insulin analogs have these same effects.  Going on intensive insulin therapy is associated with fat weight gain (1), for people with both type 1 and type 2 diabetes.  Some of the weight gain comes from that if you’re using insulin to keep your blood glucose in control, you’ll be keeping and storing all of the calories that you’re eating instead of losing some glucose through urine (during hyperglycemia).  Unfortunately, this realization has led some people to try skipping or limiting 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

Having said that, I have to say that 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, just 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 for weight management with diabetes is a balanced diet, nothing too extreme in any direction.  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 usually works to put fat into storage depots around the body.

My trick is not to completely avoid carbs, but rather to choose them wisely—eating more lower glycemic index, or GI, 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 on when the carbs are long gone and the insulin is still hanging around.  Remember, 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 afterward.

Besides, insulin requirements are determined by more than just carbs, as finally proven in a study in 2013 showing that eating fat with the same number of carbs increases insulin requirements (3). (I knew this through personal experience already!)  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 before I even heard back from her.

This phenomenon (gaining weight from treating lows) is not uncommon 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, and they can result in weight gain.

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 to 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.

                                                                                                                                                           

References:

  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. (http://www.ncbi.nlm.nih.gov/pubmed/20536510)
  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. (http://www.ncbi.nlm.nih.gov/pubmed/18466215)
  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. (http://www.ncbi.nlm.nih.gov/pubmed/23193216)
  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. (http://www.ncbi.nlm.nih.gov/pubmed/21355723)
  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. (http://www.ncbi.nlm.nih.gov/pubmed/22817453)

Taking Insulin? Avoid Getting Fat!

fat upload

A lot of people with type 2 diabetes delay going on insulin for as long as possible because they’ve heard horror stories about how much weight it can make them gain (or maybe they just don’t like shots), but people with type 1 don’t have a choice.  While it is true that insulin treatment is often associated with weight gain and more frequent bouts of hypoglycemia (low blood sugar), the real question is, why?

Some theories to explain insulin-induced weight gain are that when using insulin, your blood sugar is (usually) better controlled and you stop losing some of your calories (as glucose in your urine when your blood sugars exceed your urinary threshold) and that you may gain weight from having to eat extra to treat any low blood sugars caused by insulin. If you’re taking oral medications to lower your blood sugar and they are not working, however, insulin may be your main option for better control.

A few research studies have looked at whether weight gain is simply a result of eating more when you’re on insulin. One such study found that weight gain was not due to an increase in food intake, but rather that your body may increase its efficiency in using glucose and other fuels when your glycemic control improves—making you store more available energy from the foods you eat as fat (even if you’re eating the same amount as before you went on insulin) (1).

So, what can you do to avoid weight gain if you have to take insulin?  First of all, you should try to keep your insulin doses as low as possible because the more insulin you take, the greater your potential for weight gain is.  The best way to keep your insulin needs in check is to engage in regular physical activity.  By way of example, some people with type 2 diabetes who were studied gained weight from insulin use while others did not.  Interestingly, the main difference between the “gainers” and the “non-gainers” was that the gainers were less physically active (2). Moreover, in people with type 1 diabetes, taking insulin doses that effectively manage blood sugars can also lead to weight gain, but increases in activity levels have been shown to prevent getting fatter (3).

During any physical activity, your muscles can take up blood glucose and use it as a fuel without insulin and then following exercise, your insulin action is heightened for a few hours and as long as 72 hours—meaning that you will need smaller doses of insulin to have the same glucose-lowering effect.  It is my personal experience that regular exercise is the best way to prevent insulin-induced weight gain, but your insulin doses will also need to be adjusted downward to prevent low blood sugars that cause you to take in extra calories to treat them.

Second, you may be able to avoid weight gain by taking a look at the type of insulin(s) that you are using.  For example, in overweight type 2 diabetic subjects, use of once-daily Levemir (detemir) caused less weight gain and less frequent hypoglycemia than use of NPH (4), even combined with use of rapid-acting injections of a separate insulin for meals (and the same is likely true when using Lantus, or insulin glargine).  Anyone taking basal insulin alone (once or twice daily) or following a basal-bolus regimen can benefit by making sure that insulin doses are regulated effectively to prevent blood sugar lows and highs—while using as little insulin as absolutely necessary to get the desired glycemic effect.

In other words, the type of insulin you use and the doses you take are both important to consider in the overall management of your diabetes and your body weight, regardless of which type you have. Just as importantly, though, is how you choose to manage your lifestyle, both your exercise and your dietary choices.  Changes in your lifestyle, such as cutting back on refined carbohydrates that require larger doses of insulin to cover them and exercising regularly, are likely your best bets to counteract any potential weight gain caused by insulin use.  An added side benefit is that if you have type 2 diabetes and start exercising regularly, you may actually lose fat weight and be able to lower your insulin doses more or get off of insulin injections completely.

References cited:

  1. Jacob AN et al. Weight gain in type 2 diabetes mellitus. Diabetes Obes Metab. 2007 May;9(3):386-93.
  2. Jansen HJ et al. Pronounced weight gain in insulin-treated patients with type 2 diabetes mellitus is associated with an unfavourable cardiometabolic risk profile. Neth J Med. 2010 Nov;68(11):359-66.
  3. Jacob AN et al. Potential causes of weight gain in type 1 diabetes mellitus. Diabetes Obes Metab. 2006 Jul;8(4):404-11.
  4. Fajardo Montañana C  et al. Less weight gain and hypoglycaemia with once-daily insulin detemir than NPH insulin in intensification of insulin therapy in overweight Type 2 diabetes patients: the PREDICTIVE BMI clinical trial. Diabet Med. 2008 Aug;25(8):916-23.