Category Archives: Resistance Training

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
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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.

Interactions of Exercise and Medications (for Diabetes or Other Things)

Kayley Wolf testing basketballSome prescribed medications, including some of the oral diabetic medications, can affect your body’s response to exercise. For example, certain sulfonylureas increase your risk of developing hypoglycemia. Older-generation sulfonylureas (such as Diabinese and Orinase) cause insulin release from your pancreas and somewhat decrease your insulin resistance. However, these older medications typically have a longer duration of up to 72 hours, giving them the greatest potential to cause your blood sugars to go too low during and/or after any physical activity. Newer sulfonylureas, such as Amaryl, DiaBeta, Micronase, and Glucotrol, generally don’t last as long and carry a smaller risk of causing hypoglycemia. Of this type, DiaBeta and Micronase carry the greatest risk due to their slightly longer duration (24 hours versus only 12 to 16 hours for the others). You should check your blood sugars more often when exercising if you take any of the sulfonylureas that stay in your system longer. When your exercise becomes regular, you may need to check with your health-care provider about lowering your doses of these medications if you experience more frequent lows.

Other medications may not affect your glycemic response to exercise. Insulin sensitizers like Avandia and Actos mainly affect the action of your insulin at rest, not during exercise, so their risk of causing exercise hypoglycemia is almost nonexistent. Similarly, Glucophage is unlikely to cause exercise lows. Prandin or Starlix use only potentially increases your risk if taken immediately before prolonged exercise since they increase insulin levels in the blood only temporarily when taken with meals. Finally, medications that slow down the absorption of carbohydrates (Precose and Glyset) would not directly affect exercise, but could slightly delay your treatment of a low by slowing the absorption of carbohydrates you eat to treat it.

If you use insulin, you face a potentially more complicated exercise-medication interaction. Understanding the effects of insulin action and different regimens on glycemic control is one of the best strategies for optimizing exercise management. Both insulin and muscular contractions evoke separate mechanisms that cause you to take up glucose into your muscles, and they additively increase muscle glucose uptake. Consequently, the type of insulin that you use and the timing of its use can have a large effect on glycemic responses. You may be one of the many individuals who use a combination of short- and long-acting insulins (varying by time to peak action and total duration) given two to four (or more) times daily, or you may receive a continuous infusion of short-acting insulin through an insulin pump.

When no more than minimal (basal) levels of insulin are circulating in your body during exercise, your blood glucose response will be more normal, more like someone who doesn’t have diabetes. If you exercise when your insulin levels are peaking, however, you’ll have an increased risk of hypoglycemia. For example, if you inject intermediate-acting N at breakfast, it will peak around noon and exert its effects throughout the afternoon; if you exercise then, your blood sugars may drop more rapidly than at other times. If you use only Lantus or Levemir, both provide basal insulin coverage for 24 hours, making a separate dose of short-acting insulin required to cover lunch if your body no longer makes much insulin. Either basal insulin by itself, with no rapid-acting insulin (or if your last injection of rapid-acting insulin has peaked and waned before you start exercising), will result in a lower risk of hypoglycemia. Similarly, insulin pump users can normalize their response to exercise by either disconnecting their pumps or reducing programmed basal rates during physical activity; some users also decrease their basal rates before and/or after the activity, depending on how long it lasts and on their individual blood sugar responses.

Besides taking medications for diabetes control, you may also need help controlling your blood lipids (especially cholesterol levels), hypertension, and other coexisting health problems. Most medications taken for nondiabetic reasons will not affect your exercise response directly–with a few notable exceptions. Certain medications taken to treat high cholesterol levels or abnormal levels of blood fats (i.e., the “statins,” including Lipitor, Mevacor, Pravachol, Crestor, and Zocor) may result in unexplained muscle pain and weakness with physical activity, possibly by compromising your muscles’ ability to generate energy; however, case reports of muscle cramps during or after exercise, nocturnal cramping, and general fatigue show that these symptoms resolve when you discontinue taking the statins. If you are taking a statin and experience any of these symptoms with exercise, talk with your doctor about possibly switching to another type of cholesterol-lowering drug. Moreover, any medications taken to reduce your body water levels (diuretics like Lasix, Microzide, Enduron, and Lozol) and improve your blood pressure can lead to dehydration and dizziness from hypotension (low blood pressure), but will not likely affect your blood sugars. Vasodilators such as nitroglycerin allow more blood to flow to your heart during exercise, but they can also induce low blood pressure, which may cause you to faint during or following an activity. You’ll also experience a dramatic effect with beta-blockers (Lopressor, Inderal, Levatol, Corgard, Tenormin, Zebeta, and others) taken to treat heart disease and hypertension, as they lower both your resting and exercise heart rates; if you are taking a blocker, your heart rate will not reach any age-expected value at any intensity of exercise.

Kayley Wolf testing basketballOn the other hand, if you are taking either ACE inhibitors (Capoten, Accupril, Vasotec, Lotensin, Zestril, etc.) or angiotensin II receptor blockers (ARBs, such as Cozaar, Benicar, and Avapro) to reduce your blood pressure and/or protect your kidneys from possible damage, you should expect no negative effects during exercise. In fact, using certain ACE inhibitors may lower your risk of untoward cardiovascular events if you have heart disease. Other medications taken to treat heart disease and hypertension (calcium-channel blockers like Procardia, Sular, Cardene, Cardizem, and Norvasc),depression (Wellbutrin, Prozac, and others), or chronic pain (Celebrex) will have no effect on your ability to exercise safely and effectively. Keep in mind, though, that aspirin and other blood thinners (such as Coumadin) have the potential to make you bruise more easily or extensively in response to athletic injuries.