Category Archives: Muscle Mass

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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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

Muscle Primer: What It Is, Why It Matters

Gary Hall Jr (T1D)Muscle mass is likely the most important tissue in your body when it comes to managing insulin action and blood glucose levels. It is also one of the most important things to maintain to live well and independently as you age. In other words, you can’t afford to lose your muscle mass if you want to live long and well.

What exactly is muscle? It’s comprised of about 20 percent protein, with the rest mainly made up of water plus a few minerals and some carbohydrate and fat stores. We generally talk about having two types of muscle fibers, slow twitch and fast twitch, which refers to the speed at which the contractile proteins can do their work and be ready to contract again. Their speed determines whether they’re good for doing long, slow endurance exercise (slow twitch) or explosive power activities like sprinting (fast twitch).

Muscle fibers are still currently categorized into three types in humans: slow oxidative (SO, or Type I), fast, oxidative glycolytic (FOG, or Type IIa), and fast glycolytic (FG, or Type IIx). The Type IIb fibers we used to think that humans had only exist in lower mammals like rats apparently; we have Type IIx instead. Oxidative fibers can use a variety of fuels during activities, including carbohydrates, protein and fat, which is why they’re recruited for doing activities lasting longer than two minutes. Glycolytic fibers primarily use glycogen (stored glucose) readily available in muscle and other compounds in muscle like ATP and creatine phosphate that can only fuel activities for 10 seconds or less; accordingly, these fibers are only adequately fueled during shorter activities (30 seconds to two minutes) or bursts of speed or power.

In reality, muscle fibers really exist on a continuum from slow to fast and oxidative to glycolytic, and specific exercise training can make them change some of their metabolic and speed capabilities (1). They are recruited in a step-wise fashion, meaning that the harder an activity becomes or the more power or force you need to produce, the more fibers get recruited. You start with the slower ones since they’re hard to fatigue—which is good since they’re in postural muscles—and then add in the faster fibers as needed to produce more power or speed.

To be honest, the muscle fiber types you have (or don’t have, based on genetics) are not nearly as important as recruiting as many of them as possible when you train. As you age, you lose the muscle fibers that you don’t use regularly. Since it’s unusual for older individuals to sprint or lift heavy weights, the natural losses include more of the faster twitch fibers that are normally used to produce power and speed. Of course, that means that you are also losing some of your strength over time, which can make it harder to do ordinary things or even basic self-care.

Recently, I have had online “altercations” with a number of people zealous about their latest fitness training craze, CrossFit (CF), when I have suggested that CF may not be appropriate for many older individuals with diabetes and that many CF trainers have inadequate training to really teach proper form to prevent injuries. Many CF enthusiasts also seem unwilling to consider that some of the more tried-and-true methods of strengthening and building muscle, such as progressive resistance training, actually work as well as (or better than) CF, which is known for its explosive exercises done to extreme fatigue. Recent research has shown that muscle soreness is not required for muscle remodeling and strength gains (2).

Although any type of training can cause repetitive (overuse) injuries if done excessively or with poor form, most injuries are preventable. Moreover, it is my humble opinion that any type of training that increases the risk for spine injuries in particular (i.e., CF) should be undertaken with much care and adequate precautions to prevent injuries (3). Back problems are certain to limit people’s ability to train, but having to stop training altogether when doing any type of exercise due to injuries is a sure-fire way to lose muscle mass and should be avoided.

When it comes to managing your diabetes, having more muscle mass lets you take up more blood glucose and store it as muscle glycogen. Muscles have a limit to how much they can store, and having more muscle mass results in a greater potential storage capacity, whereas losing muscle mass through aging and being inactive limits it. Enhanced muscle mass is likely the explanation for why lifestyle changes, such as those made in the Diabetes Prevention Program, are more effective in older individuals than younger ones. While aerobic activities like walking may not enhance muscle mass as much due to their lower intensity, you don’t have to improve your fitness levels to have better control over your diabetes and metabolism, as long as you exercise regularly (4).

So, do whatever you can to keep as much muscle as you can as you age, but avoid getting injured–if at all possible, which means training smart and not necessarily pushing yourself too hard all the time. Stay regularly active, do resistance training, and eat adequate amounts of protein and calories. Your good health well into your later years will be your reward!

References:

  1. Ingalls, CP. Nature vs. nurture: can exercise really alter fiber type composition in human skeletal muscle? J Appl Physiol, 97(5): 1591-1592, 2004 (http://jap.physiology.org/content/97/5/1591)
  2. Flann KL, LaStayo PC, McClain DA, at al. Muscle damage and muscle remodeling: no pain, no gain? J Exp Biol. 214(Pt 4):674-9, 2011 (http://www.ncbi.nlm.nih.gov/pubmed/21270317)
  3. Hak PT, Hodzovic E, Hickey B. The nature and prevalence of injury during CrossFit training. J Strength Cond Res. Nov 22, 2013. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/24276294)
  4. Pandey A, Swift DL, McGuire DK, et al. Metabolic effects of exercise training among fitness-nonresponsive patients with type 2 diabetes: The HART-D study. Diabetes Care. 38(8):1494-501, 2015 (http://www.ncbi.nlm.nih.gov/pubmed/26084342?dopt=Abstract)