Category Archives: News Items

Exercise Management in Type 1 Diabetes: A Consensus Statement

JDRF Consensus Statement Cover

Above you see part of the first page of a new consensus statement that comes from many of the individuals involved with the creation and launch of the new JDRF PEAK Performance Program, aimed at educating both clinicians and people with type 1 diabetes how to manage the complexities of being active. In my opinion, this recently published consensus statement on exercise and type 1 diabetes is long overdue and much needed. I managed to get the American Diabetes Association to let me chair an updated position statement (see my November blog) and include type 1 diabetes in it but, unfortunately, never just one addressing type 1 and exercise alone so this JDRF one fills a huge void.

The past decade has seen a growing number of publications related to diabetes management during exercise in people who have to either inject or pump insulin to stay alive. As you well know, whether insulin is injected or pumped, it is not being delivered where it normally ends up in a body that can release its own insulin, and this altered insulin delivery leads to alterations in hormones and blood glucose management by the liver. Normally, your liver would be able to either release or store glucose to keep your levels constant, but not without these proper hormonal signals.

Consequently, the only way you can keep your blood glucose levels normal (or near normal) with exercise is to take in carbohydrate/food, lower circulating insulin levels, or both during activities. Given that exercise is a huge stressor to normal metabolic control of blood glucose, it can make your diabetes more difficult to manage–even though exercising is generally beneficial for a number of other health reasons. This new consensus statement does an excellent job of covering all of the potential effects of engaging in differing physical activities, along with comprehensive management strategies involving changes in food intake and adjustments in basal and/or bolus insulin dosing. It also points out the many areas that need additional (or even any) research with regard to exercising with type 1 diabetes, either to enhance health or sports performance. Read it now if you haven’t already for some great advice!

Reference:

(1) Riddell MC, Gallen IW, Smart CE, Taplin CE, Adolfsson P, Lumb AN, Kowalski A, Rabasa-Lhoret R, McCrimmon RJ, Hume C, Annan F, Fournier PA, Graham C, Bode B, Galassetti P, Jones TW, Millán IS, Heise T, Peters AL, Petz A, Laffel LM. Exercise management in type 1 diabetes: a consensus statement, Lancet Diabetes Endocrinol. 2017 Jan 23. pii: S2213-8587(17)30014-1. doi: 10.1016/S2213-8587(17)30014-1. [Epub ahead of print]

 

 

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

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!

Diabetes Motion: Practical advice about exercise and fatigue solutions

Whether you’rDiabetes Motione new to exercise or a sports enthusiast, diabetes can get in the way of being physically active. To deal with this problem, I founded a new information web site called Diabetes Motion (www.diabetesmotion.com), given that I’m one of the world’s leading experts on diabetes and exercise. The mission of Diabetes Motion is to provide practical guidance about blood glucose management to anyone who wants to be physically active with diabetes.

Without a doubt, being physically active is good for the body, heart, and mind. If you are already an avid exerciser, then you know the benefits of exercise for your health and diabetes control. If you are just thinking about getting serious about sports or fitness activities, then you have a lot of positive changes to look forward to.

Exercise can help you build muscle and lose body fat, suppress your appetite, eat more without gaining fat weight, enhance your mood, reduce stress and anxiety, increase your energy, bolster your immune system, keep your joints and muscles more flexible, and improve the quality of your life. For many people with diabetes, being physically active has made all the difference between controlling diabetes or letting it control them.

What you may not know is what type of exercise or physical activity you should you be doing or how much of it is recommended for optimal health and the best blood glucose control. The good news is that you can get different (but all good) benefits from doing a variety of types of daily movement, which gives you a lot of options. In fact, exercising regularly is likely the single most important thing you can do to slow the aging process, manage your blood sugars, and reduce your risk of diabetic complications.

Need help with revving up your exercise? If your exercise performance been less than you’d hoped recently, here are some potential causes of fatigue (and solutions):

Inadequate rest time: You may be getting through your workouts well, but then fail to perform when you have races and events simply because you didn’t take enough rest time to restore glycogen and fully recover. It’s critical to cut back on your workouts (“taper”) for at least 1-2 days before a big event and keep your blood glucose in good control so your glycogen levels will be as full as possible on race/event day.

Blood glucose and glycogen stores: It’s harder for your body to restore your muscle glycogen (stored carbs) between workouts unless you’re eating enough carbs and have functioning insulin available. Your carb intake doesn’t have to be tremendous—probably just 40% of your total calories coming from carbs will suffice—but your blood glucose absolutely needs to be in good control for your muscles to restore carbs optimally.

Iron: Having low iron stores can cause you to feel tired all the time, colder than normal, and just generally lackluster. You can get a simple blood test done to check your hemoglobin (iron in red blood cells) and your overall iron status (serum ferritins). If your body’s iron levels are low (due to diabetes or non-diabetes causes), taking iron supplements can help, along with eating more red meat with lots of absorbable iron.

Magnesium: You may have a magnesium deficiency, especially if you take insulin or your blood glucose levels are not optimal. Magnesium is involved in over 300 metabolic pathways. If you’re deficient, your exercise will be compromised and you may even experience some muscle cramping. To correct a deficiency, eat more foods with magnesium in them—such as nuts and seeds, dark leafy greens, legumes, oats, fish, and even dark chocolate—but taking a supplement may also help.

B vitamins: For people with diabetes, thiamin (vitamin B1) deficiency is also a likely culprit in exercisers and can be further depleted by alcohol intake. People who take metformin to control diabetes can also end up deficient in vitamins B6 and B12, both of which are essential to exercising well. Consider taking a vitamin B complex daily.

Thyroid issues: Having lower levels of functioning thyroid hormones can cause fatigue and poor exercise performance. Have your main thyroid hormones (TSH, T3 and T4), but possibly also your thyroid antibodies if your thyroid hormones levels are normal and nothing else is helping your exercise (specifically antibodies to thyroid peroxidase), especially if you have celiac disease.

Still stumped? If you’ve been through this list and had everything check out okay, then consider other possible issues like your hydration status, daily carb intake (adding even just 50 grams per day to your diet may help), other possible vitamin and mineral deficiencies (vitamin D, potassium, etc.), statin use (some statins taken to lower blood cholesterol cause unexplained muscle fatigue), and frequent hypoglycemia.

Please visit www.diabetesmotion.com for more helpful information about being active with diabetes.