Category Archives: Resistance Training

Exercise to Lower Your Risk of Dying (Prematurely) with Type 1 Diabetes

Bob Stewart Jumping (crop)Much of the research on length of life for individuals living with type 1 diabetes is pessimist, which makes a new study released recently a breath of fresh air. Data were collected for the ongoing nationwide, multicenter, Finnish Diabetic Nephropathy (FinnDiane) Study that tracked the death rate of 2,639 study participants for an average of 11.4 ± 3.5 years (1).

In this study, participants’ leisure time physical activity was reported via a self-report questionnaire. Importantly, their physical activity and its intensity, duration, and frequency were examined related to dying from all causes and from cardiovascular events; some of these adults with type 1 diabetes already had diabetic kidney disease.

The researchers also looked at potentially confounding factors like sex, how long people had been diagnosed with type 1 diabetes and how old they were when they got it, as well as physical measures like their systolic blood pressure, triglycerides (blood fats), BMI (body mass index), and HbA1c (a measure of overall blood glucose control over two to three months).

The conclusions of this study came as no surprise to me: exercise is associated with a lower risk of premature death from cardiovascular or any other cause in adults with type 1 diabetes. Overall, 270 people died during the follow-up period, 127 of whom had kidney disease. Only exercise intensity was associated with cardiovascular mortality, with intense activity being best for preventing early death from cardiovascular events. Both how much total physical activity they got and how frequently they exercised were associated with a lower risk of dying from any cause. Prior studies have shown that exercise frequency may also matter in preventing such events, with a higher frequency of physical activity lowering the risk (2).

People with type 2 diabetes have already been shown to have a lower risk of premature death when they are physically active (3); this is also true for the adult population in general (4; 5). However, not as many studies have looked specifically at the association between physical activity and lower mortality risk in adults with type 1 diabetes. Type 1 diabetes has previously been associated with a shorter lifespan in many adults with it, particularly related to endothelial dysfunction and cardiovascular disease (6).

Earlier studies, such as the DCCT, have shown that keeping blood glucose levels in a more normal range can help lower the risk of diabetes-related complications in people with type 1 diabetes. Most deaths in this population are related to either cardiovascular events or kidney failure. Exercise has an innate ability to lower oxidative stress, which has been implicated in the development of many complications, as well as improve endothelial function (6). While regular physical activity is associated with a lower risk of early death in adults with and without type 2 diabetes, this study is one of the first to examine this association in type 1 diabetes.

While the exact amount of exercise needed to lower the risk of cardiovascular events is unknown and not determined by this study, doing any activity is arguably better than remaining sedentary. As in people without diabetes, intense activity likely is even more cardioprotective than moderate or light activity.

However, the exercise in this study was self-reported and only collected at the start of the study, making it is hard to draw definitive conclusions about how much exercise people need to do and how intense it needs to be to reduce the risk of dying.

In conclusion, as confirmed by this latest study, being physically active on a regular basis is critical to living long and well with type 1 diabetes. Remaining sedentary is far worse for your health and your longevity, so go get active!

                                                                                                                                                           

References cited:

  1. Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Tikkanen HO, Groop PH: Physical Activity Reduces Risk of Premature Mortality in Patients With Type 1 Diabetes With and Without Kidney Disease. Diabetes Care 2017;16:dc17-0615
  2. Tikkanen-Dolenc H, Waden J, Forsblom C, Harjutsalo V, Thorn LM, Saraheimo M, Elonen N, Rosengard-Barlund M, Gordin D, Tikkanen HO, Groop PH: Frequent and intensive physical activity reduces risk of cardiovascular events in type 1 diabetes. Diabetologia 2017;60:574-580. doi: 510.1007/s00125-00016-04189-00128. Epub 02016 Dec 00124.
  3. Loprinzi PD, Sng E: The effects of objectively measured sedentary behavior on all-cause mortality in a national sample of adults with diabetes. Prev Med 2016;86:55-57
  4. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, Alter DA: Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann Intern Med 2015;162:123-132
  5. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, Bauman AE, van der Ploeg HP: Daily sitting time and all-cause mortality: a meta-analysis. PLoS One 2013;8:e80000
  6. Bertoluci MC, Ce GV, da Silva AM, Wainstein MV, Boff W, Punales M: Endothelial dysfunction as a predictor of cardiovascular disease in type 1 diabetes. World J Diabetes 2015;6:679-692
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Resistance Training When You’re Older or Have Limited Mobility

In addition to aerobic activities, you can greatly improve your blood glucose by doing some resistance, or weight, training. Like so many systems in the body, if you don’t use all your muscle fibers, you lose them over time. Anyone past the age of 25 is slowly losing muscle mass, which decreases how many carbs you can store in your muscles as glycogen. You need to retain as much of your muscle mass as possible—and gain more muscle if you can.

If you’re older or have physical limitations, working on your muscular strength helps prevent loss of muscle mass and bone density. The goal of resistance training is increased muscular fitness, both strength and endurance. Regardless of what you type you choose, engaging in any resistance training is always better than doing none.

What should you do if you’re just starting out? Choose among using resistance bands, free weights, resistance machines, or body weight as resistance (for example, doing planks or lunges). The main difference is the intensity of training. For each workout, try to do at least eight to 10 different resistance exercises (at least six to start) that work your full musculature (upper body, lower body, and core). If nothing else, start with strength training exercises that use your own body weight as resistance (like planks, lunges, or wall or modified knee push-ups). Resistance bands, dumbbells, and household items used as resistance (e.g., full water bottles and soup cans) also all work to do these exercises at home on your own. Most training can be done seated for those with mobility and balance issues.

How often should you train? You should ideally perform resistance training at least 2 nonconsecutive days each week, preferably 3. Working the same muscle groups daily doesn’t allow adequate time for recovery and muscle repair between workouts, but if you want to resistance train more than 3 days per week, you can alternate muscle groups when you train on consecutive days. Doing it as infrequently as one day a week can still be beneficial for muscle mass and insulin action.

How hard should it feel? You can gain or maintain strength by doing anywhere from 3 to 15 repetitions per set on each exercise and 1 to 3 sets, with rest between multiple sets. Generally, working up to doing 8 to 12 repetitions and two to three sets is recommended, although you can get stronger from just doing a single set. Start with an easier weight and more reps, and gradually work up to more resistance and fewer reps. If you have joint limitations or other health complications, complete 1 set of exercises for all major muscle groups, starting with 10 to 15 repetitions and progressing to 15 to 20 repetitions before adding extra sets. Your muscles should be working hard during the last 3 to 4 reps in each set, regardless. If it feels too easy, try a heavier resistance or weight; if you can’t complete your goal number of repetitions, try using a lighter amount.

What else do you need to do? Make sure to warm up your muscles and joints before starting resistance training. The best way to warm up if not also doing an aerobic workout is to go through the same motions that used for the workout, but without any resistance. Take time to have them stretch any muscles that feel tight during workouts, since that will help with increasing both flexibility and strength.

How can you avoid getting injured? To avoid injury or work around your existing joint limitations, progress slowly toward working out harder or more frequently. It’s generally better to increase your weight or resistance first—only the number of reps you’re doing is way too easy—and only then increase your number of sets and lastly add in additional training days. Expect that is should take you six months or more to progress up to doing 3 days per week (and only if you want to) and doing up to 3 set of 8 to 10 reps each—an optimal goal for most adults with diabetes.

Resistance Training Goals, Recommendations, and Precautions:

  • Short-term goal: 1 to 2 times per week, 6 to 8 exercises to start
  • Long-term goal: 3 days per week, 10 to 12 exercises
  • 2 to 3 sets per exercise
  • 10 to 15 reps per exercise to start; 8 to 12 reps per exercise later on
  • Start slowly with training and build up
  • Don’t resistance train the same muscle groups more often than every other day
  • Gradually increase resistance or weights over time
  • Perform exercises with slow controlled movements
  • Extend limbs and use the full range of motion around each joint being worked
  • Breathe out during exertion, and always avoid breath holding
  • Stop exercise if dizziness, unusual shortness of breath, chest discomfort, palpitations, or joint pain occurs

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

Should You Do CrossFit Training with Diabetes?

Allison Hirsh Caggia (T1D) brighterWith all the exercise training fads out there, it can be hard to navigate the landscape with diabetes. I am frequently asked about the latest training techniques or gym trends, so I want to specifically address a recent craze, CrossFit training, with regard to whether it’s appropriate and/or advisable for people with diabetes.

In brief, CrossFit training is a strength and conditioning program consisting mainly of a mix of aerobic exercise, gymnastics (body weight exercises), and Olympic weight lifting. Its programming is decentralized, but its general methodology is used by thousands of private affiliated gyms around the world. CrossFit, Inc., licenses the CrossFit name to gyms for an annual fee and certifies trainers, but the actual programs vary tremendously from site to site.

A concerned young man with type 1 diabetes contacted me to ask whether it’s safe for him to do CrossFit. Although he was already doing and benefiting from CrossFit training, he became concerned about it after reading a blog online by a Paleo diet advocate named Robb Wolf who, in an article about CrossFit training and type 1 diabetes, blogged that since intense training causes the liver to release excess glucose during training, people with type 1 diabetes “may be better served by mild to low intensity activities. Power Lifting, due to the low volume, might be a good option.” (This blogger also claimed that “We have seen instance of people REVERSING type 1 diabetes with a Paleo diet because they put their autoimmunity in remission.” That statement alone should make you question his credibility. If you really want to read it, please just don’t believe everything you read online, especially his blog: http://robbwolf.com/2009/08/05/type-1-diabetes-and-crossfit/#sthash.CIZdVMvp.dpu.)

My perspective is that, if you’re young and healthy and just happen to have diabetes, you should be able to engage in CrossFit training without worrying excessively about your blood glucose levels going up temporarily from doing it. To control your blood glucose, you simply have to approach it like any other intense workout, which can cause your blood glucose to go up even in people without diabetes. If you use insulin, you’ll just need to check your glucose frequently and adjust your insulin doses to make sure you have enough to stay in control both during and following your CrossFit (or other) workouts. As a side note, doing some easy cardio exercise after an intense workout can help lower your blood glucose naturally. Also, keep in mind that you’re more likely to have a bigger rise in the early AM compared to doing the same exact training later in the day (due to having more glucose-raising hormones and less insulin on board in the morning, pre-breakfast).

CrossFit does carry some risks, however. The risk of injury from some of its exercises outweighs their benefits when they are performed with poor form in timed workouts (although there are similar risks from doing other high-intensity programs incorrectly). One concern in particular is that CrossFit’s extensive online community enables anyone to follow the program without proper guidance, increasing the risk of improper form or technique that leads to getting injured. I have heard of at least one young man who caused significant damage to the cartilage in both of his knees doing such training inappropriately. When undertaken correctly, CrossFit is not inherently bad or ineffective, but beginning exercisers starting such a program may be encouraged to do too much and not be able to discern between training to failure and simply getting a good workout.

By way of example, a young woman who was a physical therapist and a regular CrossFit participant woke the morning after a particularly grueling session consisting of hundreds of reps of arm exercises and found she could not bend her elbows. She was diagnosed in the emergency room with rhabdomyolysis (“rhabdo” for short), a condition in which damaged muscles break down rapidly. This is not the first time CrossFit has been associated with rhabdo as the workouts can be particularly grueling and excessive, although any strenuous exercise can cause it. It’s worrisome because rhabdo can lead to kidney failure when excess breakdown products of damaged muscle cells (myoglobin) are released into your blood (see a video by the Mayo Clinic about exercise-associated rhabdo: https://www.youtube.com/watch?v=Hy0uEPo8-7w). Severe symptoms like muscle pain, vomiting, and confusion are symptoms of greater muscle damage and possible kidney failure. If you ever have severe muscle pain and dark colored urine, get medical attention immediately.

Exercise Performance Not Up to Par? Consider These Changes

Missy Foy (crop)Has your exercise performance been less than you’d hoped recently? There are many different things that can cause fatigue, but here are some potential causes (and solutions) to consider.

Inadequate rest time: A really simple answer to your exercise issues is that 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, repair muscle damage (caused by every workout), and fully recover. It’s critical to cut back on your workouts (“taper”) for at least 1-2 days before a big event. During that time, you also want to 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: Another thing to consider is your blood glucose control. 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. Doing longer and harder workouts can deplete glycogen stores, and you may simply just not be restoring them fully fast enough due either to your carb intake or your blood glucose management. Your carb intake doesn’t have to be tremendous—probably just 40% of your total calories coming from carbs will suffice—but you may need more if you’re not eating enough calories. Your blood glucose absolutely needs to be in good control for your muscles to store all the carbs you need to exercise optimally, so make sure your insulin is adequate and working effectively.

Iron levels: For starters, 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).  It’s possible to be iron deficient without having full-blown anemia. 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 since it has the most absorbable form of iron.

Magnesium deficiency: Most people also have issues with magnesium deficiency, especially if you take insulin or your blood glucose levels are not well controlled. Magnesium is involved in over 300 enzyme-controlled steps in metabolism, including protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. If you’re deficient in this mineral, your exercise will be compromised and you may even experience some muscle cramping (unrelated to dehydration). It’s always good to 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 (magnesium in the aspartate, citrate, lactate, and chloride forms is absorbed better than magnesium oxide and sulfate) may help. Low magnesium can also lead to potassium imbalances, which can also affect your ability to exercise well.

B vitamin intake: For people with diabetes, thiamin deficiency is also a likely culprit for exercisers, especially if they’re not eating properly. In general, the eight B vitamins are integrally involved in metabolism and even red blood cells formation. Thiamin (B1) in particular can be depleted by alcohol intake, birth control pills, and more. People who take metformin to control diabetes can also end up deficient in vitamins B6 and B12, both of which are essential to nerve function and muscle contractions. Taking a generic B complex vitamin daily can help you avoid these issues, and excesses of most of the B vitamins are harmless (and end up in your urine).

Insulin delivery method: While insulin pumps can help manage blood glucose acutely, they deliver rapid-acting insulin analogs like Humalog, Novolog, and Apidra, and these altered insulins are metabolized in the body differently than the long-acting basal one called Lantus. Rapid ones have little to no insulin-like growth factor (IGF) affinity, and most adults are reliant on IGF to stimulate muscle growth and repair rather than human growth hormone (which is only higher in youth). Lantus does stimulate IGF one, though, so you may want to talk with your doctor about combining insulin pump use (for meal boluses) with Lantus (for basal insulin coverage) to get more IGF activity to promote muscle repair. (Go with Lantus, though, as Levemir is less effective at raising levels of bioactive IGF.)

Thyroid issues: Many people with diabetes also have thyroid hormone imbalances. Having lower levels of functioning T3 and T4 can cause early fatigue and poor exercise performance, among other things. However, it may not be enough to just check your main thyroid hormones (TSH, T3 and T4); you may also want to consider getting your thyroid antibodies checked if your thyroid hormones levels are normal and nothing else is helping your exercise (specifically check for antibodies to thyroid peroxidase), especially if you have celiac disease.

Still stumped? If you’ve been through this whole 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), frequent hypoglycemia, and hypoglycemia-associated autonomic failure.

Why Resistance Training Improves the Muscle “Gas Tank”

Doug Burns (crop)

In recent years, the most compelling scientific evidence for diabetes management has been the inclusion of resistance/strength training as part of an exercise routine. Why is it so important?  Think of it this way: our muscles are the main place we have to store any excess carbohydrates that we eat, and the bigger the muscle “gas tank,” the more carbs we can store there.

The sad reality is that getting older by itself causes some loss of muscle mass over time. If you go on a diet to lose weight, you’ll also very likely to lose some muscle and not just fat–unless you resistance train. Being sedentary and having diabetes both increase the rate at which you lose muscle, and older adults with diabetes frequently have far less muscle than other people the same age. Only strength training recruits and preserves the muscle fibers that you would otherwise lose as you age, sit around too much, or have out-of-control blood glucose levels.

Being inactive only makes the problem worse because not only are you losing more muscle faster by not using it (think muscle atrophy), but the “gas tank” remains full. You’re more resistant to insulin (whether it’s naturally release, pumped, or injected) when your muscle carb stores (glycogen) are packed to their limit, which happens when you eat a lot of carbs and remain inactive. Any carbs that are unable to go into storage in muscle (or the liver) raise your blood glucose and then later are converted into and stored as fat.

You don’t even have to join a gym to make this happen. Simply start doing strength training at least two to three days per week by doing exercises using your own body weight as resistance (like planks, lunges, or wall push-ups). Resistance bands, dumbbells, and household items that can be used as resistance (e.g., water bottles and soup cans) will also all work.