Category Archives: Miscellaneous

(Why I) Count Calories, Not Just Carbs

Crate of veggiesWhenever someone gets diagnosed with type 1 diabetes (T1D) nowadays, the first thing that an educator or dietitian tries to teach them is how to count carbohydrates (carbs). Although I have been living with T1D now for almost half a century, I have to admit that I don’t count carbs. Not only that, but I personally don’t think carb counting works very well! But I also don’t avoid them.

The whole point of counting carbs is to try to balance the dose of mealtime insulin with carb intake to avoid post-meal spikes in blood glucose or hypoglycemia later on. Carbs are digested and fully absorbed within one to two hours after you eat them, and they undeniably have the most direct and dramatic impact on blood glucose levels. All carbs get broken down into simple sugars (glucose, fructose, or galactose), and the latter two (fructose and galactose) can easily be converted into glucose, which is the primary simple sugar in blood.

The problem I see with carb counting is two-fold: first, not all carbs are equal with regard to their glycemic effect (how much they raise blood glucose and how quickly) and; second, carbs are not the only component of food that can affect your blood glucose levels. Foods with a higher glycemic index (GI, found on glycemicindex.com) cause more rapid spikes in blood glucose after you eat them, but it also depends on the total amount of carbs in what you eat (the GL, or glycemic load). For example, carrots have a high GI, but their GL is fairly low, meaning that you would have to eat a lot of them to raise your blood glucose much. Pasta, on the other hand, is digested more slowly and has a moderate GI, but the load can be tremendous and enough to raise your blood glucose slowly for hours afterward.

In the first 18 years when I had diabetes without a blood glucose meter, I was taught to make every meal a balanced one (carbs, protein, and fat) and only have a certain number of servings in each category. I naturally gravitated away from eating fewer highly processed carb foods (made with white flour and white sugar) and more towards foods that didn’t make me feel crappy after eating them because they had a lower GI. To this day, I eat a lot of high-fiber, low-carb veggies (green ones like lettuce, green beans, and broccoli), only moderate amounts of starchy veggies (like corn, peas, and potatoes), and very few white carbs with a high GI. Honestly, if I were to count carbs and dose with mealtime (bolus) insulin for them, I would end up low after every meal and high later on due to how slowly my meals cause my blood glucose to rise!

The second part of the issue relates to the fact that intake of protein and fat can also impact insulin needs and blood glucose. Excess protein is turned into glucose and raises blood glucose within three to four hours after you eat it. This works well when you’re trying to prevent later-onset hypoglycemia, but not so well when you don’t have the insulin in your body to cover the rise in blood glucose naturally. Although fats are not directly converted into glucose, during rest your body will use fat over glucose, and the fats released from food make you insulin resistant for that reason. Recently, research done at the Joslin Diabetes Center showed that when people eat the same exact amount of carbs in two dinners but differing amounts of fat and calories, they have to take more insulin to cover the meal with more fat (1). I could have told them that just from personal experience!

In 2015, a systematic review (2) came up with similar findings: All studies examining the effect of fat, protein, and GI indicated that these dietary factors modify your blood glucose after meals. Late postprandial hyperglycemia was the predominant effect of dietary fat; however, in some studies, blood glucose was lower in the first 2-3 hours, possibly due to a slower emptying form the stomach. These studies also reported that high-fat/protein meals require more insulin than lower-fat/protein meals with identical carbohydrate content. Such findings point to the need for research focused on the development of new insulin dosing algorithms based on meal composition rather than on carbohydrate content alone.

 Another related problem arises from the types of insulin that people use as mealtime insulin. Back in the “dark ages” of diabetes care, I started out using what was called “Regular” insulin, which had a slow onset and lasted for many hours after the meal. Actually, I wish I still used R insulin as it would likely cover the mixed meals I eat better than the rapid-acting insulins on the market now (I’ve heard you can still buy R without a prescription, but haven’t tried getting any). The rapid-acting ones available now (Humalog, Novolog, Apidra, and inhaled Exubera) only really last for a couple of hours, and they’re really ineffective at covering the rise in blood glucose arising from fat and protein digestion and absorption long after the carbs are gone.

My personal strategy to deal with the way rapid-acting insulins work is to take higher levels of basal insulin during the day to help cover my protein and fat intake. I also check my blood glucose an hour or so after eating every meal and correct with extra insulin then based on my blood glucose level and my expected response to whatever remaining calories in the food I ate (mostly coming from low GI carbs, protein, and fat).

So, what should you do if you choose not to count carbs? Learn as much as you can about what you’re eating. Read food labels to find out how many grams of carbs, protein, and fat are in your foods. Record everything you eat and drink (and do) for at least a month and see what your unique response is to foods you eat on a regular basis. (I did this for at least a decade after I finally had a blood glucose meter to learn my individual response to everything.) It may also help to actually measure out what you’re eating with measuring cups or a kitchen scale until you get a better idea of what portions you’re taking in as well. Most Americans these days have portion distortion and eat way more than they think. Most of all, just consider more than the carbs that you’re consuming when it comes to managing your postmeal spikes effectively.

References:

(1) Wolpert HA, Atakov-Castillo A, Smith SA, 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 2013;36:810-816

(2) Bell KJ, Smart CE, Steil GM, Brand-Miller JC, King B, Wolpert HA: Impact of fat, protein, and glycemic index on postprandial glucose control in type 1 diabetes: Implications for intensive diabetes management in the continuous glucose monitoring era. Diabetes care 2015;38:1008-1015

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!

Better Dehydrated than Overhydrated during Exercise

Jen Alexander (T1D)An updated position statement on the dangers of hyponatremia (also known as water intoxication) was just released (1). It once again highlights how drinking too much water or any fluids during physical activity in the hopes of preventing dehydration can be potentially fatal.

Taking in too much fluid dilutes the sodium levels in your blood, and severely low sodium levels can lead to brain swelling, seizures, coma, and death. Less severe, symptoms of hyponatremia include nausea and vomiting, headache, confusion, loss of energy and fatigue, restlessness and irritability, and muscle weakness, spasms or cramps.

Hyponatremia has become a problem in recent years following the push to stay hydrated during all exercise, but until recently has primarily been associated with marathon races and other prolonged endurance events, especially among slow participants. Their main problem is that they don’t sweat that much, but they drink at every opportunity, often to excess over many hours due to fear of getting dehydrated. More recently, though it has been reported as being a problem during half-marathons, sprint triathlons, long hikes, yoga classes, and team sport practices and games, particularly football at all levels.

Drinking sports drinks or other fluids with electrolytes in them instead of straight water can help a little bit, but hyponatremia appears to be more related to your total fluid intake, not whether or not the drinks contain some sodium in them (2). Sports drinks containing added sodium are still more dilute than what’s in your blood, and drinking any fluids in excess during exercise can lower your blood sodium levels.

This condition is almost completely preventable. The key is simply to drink only when you feel thirsty during exercise. It really isn’t necessary to stay ahead of your thirst. The small impact that slight dehydration is going to have on your performance is nothing compared to the medical emergency created by drinking too much. Listening to your “innate thirst mechanism” provides a safe and reliable guide to hydration (1).

Using thirst as your guide should not increase your risk for cramping either since dehydration may only contribute minimally to cramps, which are likely more associated with fatigue than dehydration/electrolyte losses (3). Even becoming severely dehydrated during exercise in the heat is not likely to cause muscle cramps (4).

Surprisingly, becoming dehydrated during exercise will not necessarily increase the risk of developing a heat-related illness like heat stroke either. A body mass loss of up to 3% (mostly fluid losses through sweating) was found to be tolerated by well-trained triathletes during an Ironman competition in warm conditions without any evidence of heat illnesses (5). In fact, athletes who collapse from heat illness often are quite well-hydrated, and it’s more likely that cramping and heat illnesses come from exercising too intensely. Muscles are more prone to spasms when fatigued, and heat illnesses generally occur in people who aren’t used to exercising in the heat and who continue to work out even when feeling unwell.

People with diabetes are also more likely to have electrolyte imbalances (e.g., sodium and potassium) to start with, including hyponatremia associated with extended hyperglycemia (6). As discussed in a recent article (7), an increased risk of electrolyte disturbances with diabetes can result from poorer blood glucose management, diabetes medications (some of which alter electrolyte balance), and organ damage associated with diabetes (such as nephropathy).

When it comes down to it, preventing overhydration during exercise is likely more important that worrying about the effects of dehydration.  Use thirst as your guide when you exercise, and avoid consuming excess fluids, especially during prolonged workouts or sporting events. Also, keep your blood glucose levels in better control overall prior to engaging in any activities to ensure that hyponatremia is not an issue.

References:

  1. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med. 2015 Jul 30. pii: bjsports-2015-095004. doi: 10.1136/bjsports-2015-095004. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/26227507)
  2. Dugas J. Sodium ingestion and hyponatraemia: sports drinks do not prevent a fall in serum sodium concentration during exercise. Br J Sports Med. 2006 Apr; 40(4): 372. doi: 1136/bjsm.2005.022400 PMCID: PMC2577547 (http://www.ncbi.nlm.nih.gov/pubmed/16556798)
  3. Miller KC, Mack GW, Knight KL, et al. Three percent hypohydration does not affect threshold frequency of electrically induced cramps. Med Sci Sports Exerc. 2010 Nov;42(11):2056-63. doi: 10.1249/MSS.0b013e3181dd5e3a. (http://www.ncbi.nlm.nih.gov/pubmed/20351595)
  4. Braulick KW, Miller KC, Albrecht JM, Tucker JM, Deal JE. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2013 Jul;47(11):710-4. doi: 10.1136/bjsports-2012-091501. (http://www.ncbi.nlm.nih.gov/pubmed/23222192)
  5. Laursen PB, Suriano R, Quod MJ, et al. Core temperature and hydration status during an Ironman triathlon. Br J Sports Med. 2006 Apr;40(4):320-5; discussion 325. (http://www.ncbi.nlm.nih.gov/pubmed/16556786)
  6. Palmer BF, Clegg DJ. “Electrolyte and Acid-Base Disturbances in Patients with Diabetes Mellitus.” N Engl J Med. 2015;373(6):548-59. (http://www.ncbi.nlm.nih.gov/pubmed/26244308)
  7. Beware: Diabetes Results in Significant Electrolyte Disturbances, Diabetes In Control, Issue 798, September 11, 2015 (http://www.diabetesincontrol.com/articles/53-diabetes-news/18464-beware-diabetes-results-in-significant-electrolyte-disturbances#unused)

Are You an Exercise Non-Responder?

Roger Hanney (T1D)When researchers have done studies on adults with type 2 diabetes, although the participants as a whole have a positive average response to exercise training, as many as 15 to 20 percent of type 2 exercisers have been found to be “non-responders” (1). These are individuals who appear to be resistant to the beneficial effects of exercise training of all types because exercise training for them fails to improve their A1C (overall blood glucose control), body fat, body mass index, or other metabolic measures. But are there really exercise non-responders? And, if so, are you one of them?

Some researchers have blamed the exercise “non-response” observed in a minority of research subjects on inheriting bad genes. However, a large part of the data that these scientists used to “prove” their case came from animal research. For example, successive generations of rats have been bred until they had either a very high aerobic capacity or a low one, and the researchers then applied their findings that those animals with a low aerobic capacity don’t gain the same metabolic benefits directly to humans.

People are far from being similar to lab rats, though! We’re much more genetically diverse, and our muscles can improve their aerobic capacity with training, regardless of what genes we inherited from our parents (2). In fact, a recent review of 18 training studies concluded that normal training adaptations to aerobic exercise are possible in adults with type 2 diabetes (3), again suggesting the environment is a more viable explanation for those few who don’t respond like everyone else.

What are these environmental factors? For starters, a big issue with human aerobic training is that not all individuals in exercise studies end up training similarly, despite the good intentions of the researchers. I know from training hundreds of research subjects over the years that many older people don’t push themselves as hard as they could when they’re doing the initial exercise test (especially when riding a cycle that makes their legs hurt), and their training protocol is then set up based on a lower-than-actual maximal capacity. So, they may simply not be doing as much total training or expending as many calories during exercise as others in the study.

Many older adults with diabetes also have joint issues or health problems that limit their ability to exercise, including excess body fat, high blood pressure, or nerve damage in their feet. What’s more, what people eat is seldom controlled well in exercise studies, and taking in excess food can override the benefits of exercise, including limiting how long or high insulin action is elevated and blood glucose control after workouts (4). In other words, it’s entirely possible to negate the effects of the last bout of exercise and diminish its acute (and chronic) metabolic benefits by overfeeding.

Simply being less active during the rest of the day can also impact whether you experience the expected results of doing the training. Not surprisingly, people who are more active all day long and not just during training sessions fare better as far as their metabolic health is concerned, even when exercise training is the same for all participants in a study (5).

Even the medications you take can limit your responses to doing exercise training. The most commonly prescribed medication for type 2 diabetes is metformin, and taking metformin can blunt your normal metabolic response to exercise training (6). Taking statins to lower your blood cholesterol can cause some muscular problems that may limit your ability to exercise, as can some other medications commonly prescribed for other health problems.

Even if it’s not the environment that is holding you back and you do have some genetic traits that may limit your exercise response, that certainly doesn’t mean that you won’t gain a lot of other health benefits—both physical and mental—from being more physically active. There really is no evidence that the potential to response to exercise training is limited if you have type 2 diabetes, type 1 diabetes, prediabetes, or obesity; in fact, even breaking up prolonged sitting time has measurable metabolic benefits for everyone (7). So, get up and go be active doing whatever you enjoy the most—and be as active as you possibly can all day long. Your body will thank you for it!

References Cited:

  • Stephens NA, Sparks LM: Resistance to the beneficial effects of exercise in type 2 diabetes: Are some individuals programmed to fail? J Clin Endocrinol Metab 2015;100(1):43-52
  • Pruchnic R, Katsiaras A, He J, Kelley DE, Winters C, Goodpaster BH: Exercise training increases intramyocellular lipid and oxidative capacity in older adults. Am J Physiol Endocrinol Metab 2004;287:E857-862
  • Wang Y, Simar D, Fiatarone Singh MA: Adaptations to exercise training within skeletal muscle in adults with type 2 diabetes or impaired glucose tolerance: a systematic review. Diabetes Metab Res Rev 2009;25:13-40
  • Hagobian TA, Braun B: Interactions between energy surplus and short-term exercise on glucose and insulin responses in healthy people with induced, mild insulin insensitivity. Metabolism 2006;55:402-408
  • Manthou E, Gill JM, Wright A, Malkova D: Behavioral compensatory adjustments to exercise training in overweight women. Med Sci Sports Exerc. 2010;42(6):1121-8
  • Braun B, Eze P, Stephens BR, et al.: Impact of metformin on peak aerobic capacity. Appl Physiol Nutr Metab 2008;33:61-7
  • Dunstan DW, Kingwell BA, Larsen R, et al.: Breaking Up Prolonged Sitting Reduces Postprandial Glucose and Insulin Responses. Diabetes Care 2012;35:976-983

What Is the Best Time of Day to Exercise with Diabetes?

cropped-casunset.jpgThe biggest problem most insulin users face is the risk of their blood glucose going too low for up to two days after they exercise.  Given that there are no clear recommendations about the best time to exercise with diabetes, a recent study published in the Journal of Diabetes Science and Technology early in 2015 tackled this issue head-on.

The study compared blood glucose levels and the number of lows during and following moderate exercise for 36 hours.  A total of 35 adults with type 1 diabetes using insulin pumps undertook 60 minutes of moderate exercise on a treadmill at 7 AM (pre-breakfast) and 4 PM (pre-dinner) on different days.  During exercise their insulin pumps were turned off completely and then restarted 45 minutes after they stopped working out.  How frequently they developed hypoglycemia (defined as glucose values < 70 mg/dl, or3.9 mmol/l) for up to 36 hours post-workout was monitored using both a continuous glucose monitor (CGM) and normal fingerstick tests.

What do you think they found out?  Figure 1 shows when the hypoglycemic events happened.  Overall, hypos occurred significantly less often following 7 AM exercise compared to 4 PM (5.6 vs. 10.7 hypos per person).  This is not a new finding, however, as other studies done previously in both type 1 and type 2 exercisers have found that you’re more likely to get low from exercise done later in the day.

What was Interesting about this study was that most of the lows occurred 15 to 24 hours after exercise, regardless of the exercise timing, and over half of the adults in the study had at least one low in 36 hours.  On days following morning exercise, there were 20% more CGM readings between 70 and 200 mg/dL (3.9 and 11.1 mmol/l) than on the day before they exercised in the morning, meaning that doing pre-breakfast exercise kept their blood glucose levels in a more normal range and improved their overall control, all with a lower risk of hypos.

Details about the 7 AM, pre-breakfast exercise:  Participants had 180 lows after the morning sessions (5.6 per participant during 36 hours), with most occurring 15 to 24 hours after the sessions (between 10 PM and 7 AM—just when you don’t want to go low!). When people exercised before breakfast, no one got low during or immediately after the exercise.

Details about the 4 PM, late afternoon exercise:  They had 322 hypos after the afternoon sessions (10.7 per participant during 36 hours), with most occurring 15 to 21 hours after exercise, which in this case was between 7 AM to noon. Six people got low during the exercise itself (compared to none during AM exercise).

Not surprisingly, this study reported fewer hypos when insulin users exercise at 7 AM, prior to breakfast and morning rapid-acting insulin.  At that time of day, levels of the hormone cortisol are higher, which lowers insulin action and keeps blood glucose levels from dropping, and circulating insulin is lower as well (prior to any insulin taken for breakfast).  The afternoon exercise was done at 4 PM, which was four hours after lunch and use of rapid-acting insulin, but the “tail” of any insulin taken during the day may still lead to higher insulin levels overall in the afternoon compared to in the morning.

So, when should you exercise?  I still say that the best time to exercise is when you have the time to do it on any given day.  However, if you exercise later in the day, you may have to eat more or take less insulin to prevent later-onset hypoglycemia.

One more thing to keep in mind, though, is that this study only tested moderate activity.  If you work out harder, your blood glucose is more likely to rise during the activity, which may result in hyperglycemia instead of hypos.  In that case, doing intense afternoon activity may be preferable!

If you’re a die-hard morning exerciser but get frustrated with the rise in glucose that comes with it, you can also get around that by simply “breaking” your fast before you exercise, or making your 7 AM bout of activity after you eat something instead of before.  If you have type 1, you’ll have to take a small amount of insulin (albeit much less than normal) to cover it, and if you have type 2, your pancreas should release what you need to lower the insulin resistance associated with early mornings.  You don’t have to eat a full breakfast to make this work.  So, you still have lots of options, but all come with their own issues that you’ll have to figure out to prevent exercise-induced lows.

Gomez, A. M., C. Gomez, P. Aschner, A. Veloza, O. Munoz, C. Rubio & S. Vallejo (2015) Effects of Performing Morning Versus Afternoon Exercise on Glycemic Control and Hypoglycemia Frequency in Type 1 Diabetes Patients on Sensor-Augmented Insulin Pump Therapy. J Diabetes Sci Technol.

Diabetes Rising: What Can We Do to Stop It Before It’s Too Late?

China DM and prediabetes

As if the predictions of diabetes to come were not already grim enough, a new report released by the Centers for Disease Control and Prevention now predicted that one in three American adults may have diabetes by 2050, with the number of diabetes patients projected to double or triple over the next 40 years. While the report blames the predicted increase primarily on an aging population, more members of high-risk minority groups, and longer survival in people who already have diabetes, my perspective on the cause of this epidemic is somewhat different.

Let me address these three points in order. Many chronic diseases get blamed on aging when in fact the real culprit is lifestyle choices. With diabetes in particular, the amount of metabolically active muscle mass you retain as you age has a huge impact on insulin action, given that skeletal muscles are the primary storage site for carbohydrates. If you exercise regularly and recruit all of your muscle fibers with intense or vigorous activities, you will lose less muscle mass and retain a much higher level of insulin sensitivity. If you also eat fewer refined carbohydrates that are quickly converted into blood glucose and that are lacking in fiber and essential anti-diabetic nutrients (like magnesium and vitamin D), your insulin action will remain higher as you age.

As for an increase in high-risk minority groups being the cause, let’s re-examine the case of two biologically related minority groups with completely different rates of diabetes. The Pima Native Americans of Arizona have an extremely high incidence of obesity, insulin resistance, and type 2 diabetes, with more than half of all Pima adults 35 years and older with type 2 diabetes. However, another group of Pimas from whom the Arizona group descended was discovered in Mexico, and despite sharing the same gene pool, these two groups differ dramatically in their levels of body fat. Here again, lifestyles make a difference: the Mexican Pimas are physically active farmers who eat a traditional diet of natural foods such as wheat, squash, beans, cactus buds, squawfish, and jackrabbit, while the Arizona Pimas eat highly refined, nutrient-poor foods and have a sedentary lifestyle. It should come as no surprise that the Arizona Pimas are the only ones who have type 2 diabetes.

Finally, just the fact that some people are surviving longer with diabetes (and adding to the growing number of cases) is not in itself cause for concern. Individuals with good self-care practices and adequate diabetes control are likely not developing diabetes-related health problems at the same rate as those with less healthy lifestyles and inadequate glycemic control.

What can we do to stop the rising number of cases? For starters, we have to address the causes on the personal and community levels, along with as a nation. Some small steps are being taken in that direction with the CDC’s launch of the Diabetes Prevention Program through the Y and others. Really, the bigger problem to address is that despite our knowledge of what we should be doing, most Americans are not following through on this. What we have is not a lack of motivation; rather, it is a behavior problem that is both personal and society-wide.

For example, for their safety, we strap our toddlers into strollers or keep them sitting in front of the television instead of walking whenever they can or playing outside. We keep our kids sitting and motionless during most of the school day, and then we feed them an excess of unhealthy calories for lunches and snacks. We adults stand and wait for elevators when we could take the stairs, and we stand on escalators instead of walking up and down them (even at the American Diabetes Association meetings, where everyone is supposed to know better).

What is it going to take to turn around our lifestyles for the better on a wide scale? In my opinion, we need to involve money. If all of us could have more change in our pockets if we choose a healthy lifestyle, the habits of Americans will likely finally start to change for the better. Let’s start by trying to get more health insurers interested in lowering health insurance rates for individuals with healthy behaviors, and let’s get more businesses interested in doing the same for their employees. Hopefully, we will not have to take as drastic a stand as they have in Japan, where companies are being fined based on the number of employees they have with waistlines above 32 inches. But, at this point, we have to start taking more steps in that direction instead of just wringing our hands and worrying about what’s to come (without our intervention).

Small changes can make a big difference in the health and waistlines of Americans. Just standing more each day burns calories and tips the scales in the direction of weight loss instead of further weight gain. Eating a salad with your dinner substantially lowers calorie intake at that meal, and simply taking in 50 calories fewer than you need a day can result in a five-pound loss of fat weight in a year, without any effort.

Take a stand yourself today by becoming a role model of a healthier lifestyle for everyone that you come in contact with. Use social networks to get others involved. Put your money where your mouth is. Let’s all get moving more, eating better, and staying thinner and healthier—starting today!

For Many, Doing So Little Can Have a Big Effect

Chelsea Brown (T1D) stretchingFor those of us who are reasonably fit and exercise regularly, it is hard for us to imagine that people who are currently sedentary, unfit, or overweight can benefit metabolically from doing something like simply taking breaks from sitting. However, the research in this area is now compellingly clear. Individuals with the most to gain can greatly affect their metabolic health by taking very small steps in the right direction with regard to their exercise habits.

For starters, we really need to emphasize getting up off the couch more. In newly diagnosed adults with type 2 diabetes, ages 30-80, more time spent in sedentary pursuits is associated with a larger waist circumference, meaning that they have more deleterious visceral fat. (1) However, making small changes in daily activity levels, such as taking a five-minute walking break every hour could benefit weight control or weight loss. An individual would theoretically expend an additional 24, 59 or 132 kilocalories during an 8-hour workday by simply getting up and walking around at a normal, self-selected pace for one, two, or five minutes every hour, respectively, compared with sitting for that whole time. (2) Therefore, simply taking breaks from sedentary time is a potential way to lose weight and prevent weight gain in the first place, and it likely would help prevent the onset of type 2 diabetes in the first place.

Moreover, a single bout of moderate exercise can have a more lasting effect on diabetes management than most people realize. For example, in a recent study, individuals with impaired glucose tolerance or type 2 diabetes engaged in a single session of either 30 minutes of moderate aerobic exercise or 45 minutes of moderate resistance training. (3) Amazingly, that single bout of either type of exercise substantially reduced the participants’ prevalence of hyperglycemia (defined as blood glucose levels >10 mmol/L) for the following 24 hours.

It’s not that all exercise has to be done that intensely either to have an effect. Individuals with type 2 diabetes who performed an isoenergetic bout of endurance-type exercise for 60 minutes at 35% of maximal workload (low-intensity) or 30 minutes at 70% (high-intensity) reduced their prevalence of hyperglycemia by 50% and 19% in the low- and high-intensity conditions, respectively, for 24 hours afterwards as well. (4) These results suggest that a single bout of low-intensity work may actually be more effective at lowering the prevalence of hyperglycemia throughout the subsequent 24-hour period than high-intensity work.

We usually tell people that doing daily exercise is better, but that may not be necessarily true either. When adults with type 2 diabetes either did no exercise or engaged in 60 minutes of moderate cycling exercise distributed either as a single session performed every other day or as 30 minutes of exercise performed daily and their blood glucose was monitored continuously for 48 hours, their prevalence of hyperglycemia was reduced from 32% of that period following no exercise to 24% over 48 hours following daily cycling or following cycling done every other day. Thus, it appears that as long as total caloric expenditure during exercise is matched, daily exercise can be done every other day instead and have the same glycemic results.

Since it’s so easy to have such a big impact, it’s about time we get everyone doing these activities to better manage their diabetes and their body weight. Time to stand up and walk around! Adult recess anyone?

References Cited:

1. Cooper AR, Sebire S, Montgomery AA, Peters TJ, Sharp DJ, Jackson N, Fitzsimons K, Dayan CM, Andrews RC. Sedentary time, breaks in sedentary time and metabolic variables in people with newly diagnosed type 2 diabetes. Diabetologia. 2012; 55(3):589-99.

2. Swartz AM, Squires L, Strath SJ. Energy expenditure of interruptions to sedentary behavior. Int J Behav Nutr Phys Act. 2011; 8:69.

3. van Dijk JW, Manders RJ, Tummers K, Bonomi AG, Stehouwer CD, Hartgens F, van Loon LJ. Both resistance- and endurance-type exercise reduce the prevalence of hyperglycaemia in individuals with impaired glucose tolerance and in insulin-treated and non-insulin-treated type 2 diabetic patients. Diabetologia. 2012;55(5):1273-82.

4. Manders RJ, Van Dijk JW, van Loon LJ. Low-intensity exercise reduces the prevalence of hyperglycemia in type 2 diabetes. Med Sci Sports Exerc. 2010; 42(2):219-25.

5. van Dijk JW, Tummers K, Stehouwer CD, Hartgens F, van Loon LJ. Exercise Therapy in Type 2 Diabetes: Is daily exercise required to optimize glycemic control? Diabetes Care. 2012;35(5):948-54.