Category Archives: Nutrition

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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How to Treat Lows–as Quickly as Possible

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

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

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

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

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

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

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

Reference:

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

(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

How to Improve What Really Matters: Quality of Life, Not Longevity

Active senior swimmerFor many years, I have focused on aspects of lifestyle and health management that can enhance quality of life, especially when living with diabetes, rather than simply on living a long time (longevity). Much of my motivation is derived from watching my maternal grandmother suffer through six (long) years of severe disability related to cardiovascular complications of diabetes starting at the age of 70 that left her unable to feed herself or communicate, bed bound, and with almost no quality of life for her final six years. Really, what is the point of simply being alive in that case? This topic has come up again recently. New research published online ahead of print in Diabetologia in Spring 2016 (1) presented results showing that the life expectancy and disability-free life expectancy at age 50 years were 30.2 years and 12.7 good years, respectively, for men with diabetes, and 33.9 years and 13.1 good years for women with diabetes.

Really think about what those estimates mean: If you’re female and have diabetes at age 50, you would be expected to live almost to age 84, but likely be disabled in some way from the age of 71 forward. If the disability is severe (as in the case of my stroked-out grandmother), then that is a lot of pointless years of being alive without really living, not to mention being a huge burden to your family.

Admittedly, that’s pretty discouraging. The best solution may be to focus on what we can do to prevent disability with aging rather than simply living longer. Here are three proven ways to improve your quality of life with diabetes (and likely your longevity):

Exercise regularly and be more physically active overall. Even if you already have some diabetes health issues like peripheral neuropathy, which can negatively impact quality of life, exercising regularly can help. In older adults with diabetes and neuropathy, engaging in just 8 weeks of moderate-intensity aerobic exercise improved their quality of life and led to less pain, more feeling in their feet, less restriction in their activities of daily living, better social interactions, and a greater overall life quality—just after 8 weeks of training (2). Other types of physical activity have similar and profound effects on living well with neuropathy (3), so choose what you enjoy doing the most and start with those.

Eat more fiber, found abundantly naturally in plant-based foods. We all know we should be eating more fiber, but where can you find it (besides in Metamucil, which may not have the same health benefits)? Look for it in plant-based foods, mainly fruits, vegetables, grains, beans, and nuts and seeds. Dietary fiber and whole grains contain a unique blend of bioactive components including resistant starches, vitamins, minerals, phytochemicals, and antioxidants, all of which are critical to healthy living. A higher fiber intake helps prevent or protect against health issues that can decrease both quality of life and longevity, including constipation, hemorrhoids, colon cancer, gastric reflux, obesity, diabetes, stroke, and cardiovascular diseases (4). It also keeps the healthful gut bacteria in your digestive tract more abundant, which directly can benefit health and even prevent obesity. Aim for as much as 50 grams of fiber in your daily diet for optimal health.

Improve the quality and quantity of your sleep. Both sleeping better and sleeping enough (7 to 8 hours a night for most adults) lower insulin resistance and can help improve diabetes control; alternately, not getting enough good sleep can make your blood glucose levels much harder to manage. As you age, it may require taking a melatonin supplement to help you fall asleep and improve diabetes control (5), but exercising regularly certainly assists as well, so try taking your daily dose of exercise to optimize sleep. Get started on these three easy changes today to improve your chances for living longer without disabilities. Remember, there’s more to life than living a long time. What’s the point of living longer if you can’t live well and feel your best every day of your life? It really is your choice to make because you can affect the outcome.

References cited:

  1. Huo L, et al. “Burden of diabetes in Australia: life expectancy and disability-free life expectancy in adults with diabetes” Diabetologia 2016; DOI: 10.1007/s00125-016-3948-x. 2. Dixit S, Maiya A, Shastry B: Effect of aerobic exercise on quality of life in population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, randomized controlled trial. Quality of Life Research 2014;23:1629-1640
  2. Streckmann F, Zopf EM, Lehmann HC, May K, Rizza J, Zimmer P, Gollhofer A, Bloch W, Baumann FT: Exercise intervention studies in patients with peripheral neuropathy: a systematic review. Sports Med 2014;44:1289-1304
  3. Otles S, Ozgoz S: Health effects of dietary fiber. Acta Scientiarum Polonorum Technologia Alimentaria 2014;13:191-202
  4. Grieco CR, Colberg SR, Somma CT, Thompson A, Vinik AI: Melatonin supplementation lowers oxidative stress and improves glycemic control in type 2 diabetes. International Journal of Diabetes Research, 2(3): 45-49, 2013 (doi: 10.5923/j.diabetes.20130203.02)

Losing Weight by Being Active Is Best

Rose Scovel T2D (crop)Did you know that your body stores fat from excess calories in places other than fat cells? Both your muscles and your liver store extra fat as you gain excess fat weight (1). More fat storage in your muscles may decrease the removal of glucose from your blood, making muscles more resistant to insulin if you don’t exercise regularly (2; 3). Given that your muscles are responsible for the majority of blood glucose uptake in response to insulin, developing insulin-resistant muscles has a substantial impact on your blood glucose. Regular exercisers, paradoxically, can store more fat in their muscles without experiencing insulin resistance, suggesting that the total amount of fat stored there isn’t the critical component but rather how muscles respond to insulin (4).

The greater release of insulin that results from eating excessive amounts of carbohydrate may cause you to gain body fat because carbohydrates are usually converted into and stored as fat when you’re sedentary. If you store fat just in fat cells (particularly in the ones under the skin), you probably will not have as many health problems compared to putting it elsewhere. For example, storing extra fat in your liver may contribute to low-level inflammation, which can lead to the development of insulin resistance, diabetes, heart disease, and other metabolic disorders. Therefore, your liver (and whether or not it stores excess fat) may prove to be a crucial link between weight gain and the development of insulin resistance (1).

An insulin-resistant liver may lead to elevated blood fats and cholesterol levels that contribute to the development of heart disease. You can compound the problem by with dietary choices that contribute to your liver’s insulin resistance, including foods high in refined carbohydrates and highly processed ones. You can lower inflammation and improve your metabolic health with lifestyle changes, including exercising more (5). In fact, being active and eating more fiber naturally in your diet are likely the two most important changes you can make to lower your risk of all metabolic diseases (6).

You don’t have to lose a lot of weight: losing just ten pounds improves your insulin action, lowers inflammation, enhances good cholesterol and lowers the bad, improves metabolic efficiency, and reduces type 2 diabetes risk. Going on a diet to lose weight, however, is not the best long-term solution to managing your body weight or reducing your diabetes risk.

Why? Dieting does not work for most people. It becomes progressively harder to lose weight the longer you stay on a diet (thus making it harder for you to stay motivated to follow it); consequently, many people give up after a while.

A bigger problem is that you are not likely to keep off any weight that you do lose. More than nine out of ten dieters who have successfully lost weight ultimately regain the pounds they struggled to lose. If you go back to eating the same foods after your diet ends that you ate before, you will typically rebound by taking in excessive calories, particularly in the form of extra fat that quickly returns you to your former weight. In fact, most people gain back even more than they lost, regardless of the diet they followed. A greater percentage of the weight you regain is usually body fat, ultimately making your body fat higher than if you had never lost any weight.

While your body’s set point—or what you normally weigh—can change gradually over your lifetime, it remains the same over the relatively short time frame of a diet, unless you make permanent lifestyle changes. If you maintain high levels of daily physical activity while you’re losing weight, though, that will help you prevent gaining it back later on (7). So, if you have to choose between dieting and being more active to lose weight, always choose motion, even if weight loss is slower with exercise alone.

References:

  1. Koska J, Stefan N, Permana PA, Weyer C, Sonoda M, Bogardus C, Smith SR, Joanisse DR, Funahashi T, Krakoff J, Bunt JC: Increased fat accumulation in liver may link insulin resistance with subcutaneous abdominal adipocyte enlargement, visceral adiposity, and hypoadiponectinemia in obese individuals. Am J Clin Nutr 2008;87:295-302
  2. Coen PM, Dube JJ, Amati F, Stefanovic-Racic M, Ferrell RE, Toledo FG, Goodpaster BH: Insulin resistance is associated with higher intramyocellular triglycerides in type I but not type II myocytes concomitant with higher ceramide content. Diabetes 2010;59:80-88
  3. Coen PM, Goodpaster BH: Role of intramyocelluar lipids in human health. Trends Endocrinol Metab 2012;
  4. Bergman BC, Butterfield GE, Wolfel EE, Casazza GA, Lopaschuk GD, Brooks GA: Evaluation of exercise and training on muscle lipid metabolism. Am J Physiol 1999;276:E106-117
  5. Zoppini G, Targher G, Zamboni C, Venturi C, Cacciatori V, Moghetti P, Muggeo M: Effects of moderate-intensity exercise training on plasma biomarkers of inflammation and endothelial dysfunction in older patients with type 2 diabetes. Nutr Metab Cardiovasc Dis 2006;16:543-549
  6. Herder C, Peltonen M, Koenig W, Sutfels K, Lindstrom J, Martin S, Ilanne-Parikka P, Eriksson JG, Aunola S, Keinanen-Kiukaanniemi S, Valle TT, Uusitupa M, Kolb H, Tuomilehto J: Anti-inflammatory effect of lifestyle changes in the Finnish Diabetes Prevention Study. Diabetologia 2009;52:433-442
  7. Wang X, Lyles MF, You T, Berry MJ, Rejeski WJ, Nicklas BJ: Weight regain is related to decreases in physical activity during weight loss. Med Sci Sports Exerc 2008;40:1781-1788

Muscle Cramps: Inevitable or Preventable with Physical Activity?

Ginger Vieira (T1D)If you experience painful, involuntary contractions of your muscles, you’re having a muscle cramp. They can occur in any muscle but are most common in the legs, feet, and muscles that cross two joints, such as your calf muscle (the gastrocnemius, which crosses your knee and your ankle joints), quadriceps and hamstrings (the front and back of your thighs), and your feet. Not all of them are that painful; they range in intensity from a slight twitch to severe cramping that makes the muscle feel rock hard and that can last from a few seconds to several minutes. They can also ease up and then re-cramp several times before disappearing.

Although the exact cause of muscle cramps remains unknown, they are not inevitable. More than likely they’re likely related to either poor flexibility, muscle fatigue, and/or doing new physical activities. Athletes are more likely to get cramps in the preseason when less conditioned and more subject to fatigue. Cramps often develop near the end of unaccustomed intense or prolonged exercise or during the night following the activity.

Of course, if you’re exercising in the heat, cramps can also be related to dehydration and depletion of electrolytes (sodium, potassium, magnesium, and calcium) lost through sweating. When these nutrients fall to certain levels, you’re more likely to experience cramping, and it’s good to keep in mind that many people with diabetes already have low blood levels of magnesium. In people with diabetes, taking magnesium supplements may help reduce cramping issues. The other electrolytes like potassium and sodium can also become unbalanced during periods of uncontrolled hyperglycemia when water losses through urine are usually greater. Finally, cramps may also occur as a side effect of certain medications and other substances, such as lipid-lowering agents (statins in particular), antihypertensives, beta-agonists, insulin, oral contraceptives, and alcohol.

Cramps usually go away on their own without treatment, but there are effective ways to deal with them. For starters, stop the activity that is causing your muscles to cramp (if you can). Then, gently stretch and massage the cramping muscle, holding your joint in a stretched position until the cramp stops (such as pulling your toes toward the top of your foot if your calf muscle is cramping).

To try to prevent cramps, increase your fitness level and avoid becoming excessively fatigued during an activity. They appear to be best prevented by reducing the risk of developing premature muscle fatigue. Warm up before you start intense workouts and stretch regularly when you’re done exercising, focusing primarily on your calves, hamstrings, and quads. Avoid pointing your toes if your calves are involved. Also, always make sure to stay adequately hydrated, especially when exercising in hot and humid environmental conditions, and eat a wide variety of healthy foods that will help replenish lost electrolytes naturally. Supplementing with sports drinks can help replenish electrolytes as well, but they add excess calories and extra (rapidly-absorbed) carbohydrates, making them less desirable in most instances except when more carbohydrates are needed during exercise to prevent hypoglycemia (low blood sugars).

In summary, there are many possible causes of muscle cramps, but they do not inevitably result from physical activity prevention. Taking some simple precautions can prevent them (such as preventing dehydration and extreme fatigue during activities), and cramps can also be effectively treated if they do occur on occasion.

Does Low-Carb Eating Compromise Your Ability to Exercise?

Bill Carlson running (crop)I have had many people ask me recently if they can follow a low-carb diet and still do significant exercise training and events — individuals with both Type 1 and Type 2 diabetes. Not all of us follow the “low-carb” mantra (even if we moderate our carbohydrate intake), but enough people do it fairly strictly, making it an issue that needs clarification. I’m not a carb advocate person, but I do know the positive effect that carbs in moderation can have on sports and athletic performance and your general ability to do regular physical activity of any sort.

In spite of your body’s improved use of fat and ketones after you have been on a low-carb regimen for several weeks, it’s an undeniable fact that fat will never be your body’s first choice of fuel during moderate and intense workouts lasting more than a couple of minutes. If carbs are available, your body will use them over fats, especially as your workout gets more intense. It simply comes down to how the body works, and using carbs is more fuel efficient — that is, you get more energy out of carbs for a given quantity of oxygen (5.05 vs. 4.7 calories per gram for carbs and fats, respectively). Carbs are like using a higher-octane fuel, resulting in more miles to the gallon. If you want to exercise intensely and you eat a low-carb diet, you will simply not be able to perform at the highest level possible. However, if you’re eating enough calories to cover your body’s basal needs and your exercise use, you can easily get by with 40% or less of your calories coming from carbs. Eating more carbs than that will not necessarily benefit exercise (it is NOT a case of “some is good, so more is better”). I do believe that most people who are training overdo their carb intake, given the limited amount and intensity of training that they do. For example, you really don’t need to eat a huge pasta dinner the night before you do a 5K (3.1 mile) run.

It does take 24 to 48 hours to fully restore the muscle glycogen that you deplete during exercise, but that time frame assumes that you’re eating adequate amounts of carbs. If you’re on a low-carb dietary regimen, it will inevitably take longer than expected, and you may be trying to do your next workout with less muscle and liver glycogen available. Being glycogen depleted also does not necessarily improve your fat use because, as we say in the exercise physiology world, “fat burns in a carbohydrate flame.” If your muscles are glycogen depleted, your fat use will be somewhat compromised, and you’ll have to slow down your pace for that reason as well.

Low-carb eating and exercise has not been well studied in diabetic individuals, but let me give you a recent published example of its effects in a non-diabetic population during a single session of exercise to exhaustion done at a high intensity. Keep in mind that this study is related to optimal performance at a higher level, not the mild or moderate activity done during an average exercise session like brisk walking for an hour.

The study, published in Brazilian Journal of Medical and Biological Research in late 2009, examined the effects of lowering carbohydrate intake for 48 hours and its effect on the time to exhaustion during moderate and heavy exercise. Seven men participated in a randomized order in two diet and exercise regimens each lasting 3 days with a 1-week interval for washout. After doing a glycogen-depleting bout of exercise, the men ate a diet with either 10% or 65% of calories derived from carbohydrates for the two days before testing. The researchers found that subjects only had problems with early fatigue during the higher-intensity exercise done in a more glycogen-depleted state, but not during the lower-intensity exercise. They concluded that this finding may be related to an inability of fat oxidation to substitute for muscle glycogen oxidation at high exercise intensities. The glycogen-depleted subjects did have a greater fat use during exercise, but the exercise also felt harder to them (i.e., their perceived effort with low glycogen levels was higher). Admittedly, if all of your exercise training and competing is going to be done at a submaximal level (with your goal being just to finish and not to be competitive), then this study may not be that relevant to you.

Do you really need to restrict carbs so severely if you’re exercising regularly? Probably not. Even people with Type 2 diabetes will be able to handle carbs better when doing regular physical activity that depletes some muscle glycogen (the main storage depot for excess carbohydrate consumption), and they may feel less tired and more energetic when eating some carbs during and/or after exercise in particular to speed up muscle glycogen repletion. On rest days, a lower carb diet is certainly better for everyone (even people without diabetes). For individuals with Type 1 diabetes, it’s also critical to keep your blood sugars in good control to optimize muscle and liver glycogen restoration; it won’t be effectively restored if your sugars are running too high.

Taking in some carbs post-exercise is probably the most important time — during that “window of opportunity” from 30 minutes to 2 hours afterwards when glycogen repletion rates are highest — which is also when your body will need the least amount of insulin to cover any carbs you eat. It doesn’t necessarily have to be a lot; you can start out with maybe 15-30 grams, depending on how long and hard you worked out.

I have to reiterate, though, that your body cannot process fat as quickly or as efficiently as carbs during exercise (the lower number of calories derived from oxygen per gram of fat is a non-disputable fact), so you will never reach your peak performance for high-intensity exercise relying on fats alone. If you can still do less intense exercise as well as you’d like to while using more fats than carbs and optimal performance is not your concern, then a low-carb lifestyle and moderate exercise may work just fine for you.