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

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

Head Scratching Days with Insulin Action Changes

SB sprint subject (and Sheri)

The topic of insulin action (resistance and sensitivity) has come up multiple times over the years in my articles and posts, but it is admittedly much more complex than I often make it out to be. In a DiabetesInControl article I posted last summer, you can find a short list of all the factors that can potentially improve insulin action (basically insulin sensitivity). In reality, though, sometimes it is impossible to know exactly what is affecting it.

Recently, I spent the majority of two days traveling in a car and not exercising, and I reached the point where I could barely eat anything without my blood glucose rising over 200 mg/dL, even when giving twice or three times my usual insulin dose for the same food. Just sitting in a car and not exercising resulted in full muscle glycogen stores, with no room to store more carbohydrate—hence the resulting muscular insulin resistance. Even I was frustrated by dealing with my lack of immediate control, even though I knew that physical inactivity was the cause.

Based on my personal experience, I want to take some of the burden of always being on top of blood glucose levels off of anyone with diabetes. Sometimes you can do everything right and your insulin action can still less (or more) than expected. It’s not necessarily your fault, nor can you always anticipate how to best combat it.

Here is my short list of factors from my personal experience that can make people insulin resistant one day and insulin sensitive the next—and not always as you would expect. I call those the “head scratching days,” but sometimes it’s more like hair pulling!

  • If you’ve had a prior hypoglycemic event

Going too low and staying there for a while (such as during sleep) may increase insulin resistance more than just having a simple hypo event and treating it quickly. Morning insulin resistance is the most variable anyway (higher levels of cortisol then). It is admittedly my most frustrating time of day since often the same exact breakfast and starting blood glucose level will result in a different rise in blood glucose levels. Sometimes an overnight low explains it, but sometimes it doesn’t.

  • If your blood glucose has been running high

Hyperglycemia begets more hyperglycemia because it causes insulin resistance. That is why sometimes it takes way more insulin than you would expect just to get back to a normal level, and it may take hours. Try not to overdose on insulin in the meantime (especially you’re your bedtime) or you’ll end up low and back on the blood glucose rollercoaster.

  • If you’ve drastically changed your normal exercise patterns

Heightened insulin action due to your last workout is fleeting, and sitting in a car for two days is a dramatic change for me, particularly since my basal and other insulin doses are set for being active, not for being inactive. Even a week of detraining (due to injury, vacation, sickness, or other life event) can cause insulin resistance to rise rapidly in everyone, not just in people with diabetes. If you start working out more overall or just more regularly, your overall insulin needs (including basal) may also decrease. Just try to be as consistent as possible to make it easier for yourself to manage.

  • If you ate more calories, fat, or protein than you realized

Eating out at restaurants is really hard for me because no matter what I order, it seems like it takes two to three times my usual insulin doses to cover it. It is likely because protein and fat kick in and affect blood glucose levels later on (3-6 hours after a meal) and restaurant meals have more calories in them than most home-cooked meals. Fat, sugar, and salt keep people coming back to the restaurant for more! You can strategically use protein and fat intake overnight or after exercise to help prevent later-onset lows, though.

  • If you’re stressed, mentally or physically

It is truly amazing how much of an impact that stress has on blood glucose levels. Just try going to court (if you’re not an attorney) and keep your blood glucose in check while your adrenaline is pumping. Your cortisol levels also go up and raise blood glucose. So, just being stressed out during the day, or being exhausted or sick (physical stress), can cause insulin resistance. Try to take deep breaths and get some exercise during the day to combat both the stress and the resulting insulin resistance. Getting sick and running a fever or having an infection can also drive your blood glucose and insulin needs up.

  • If you’re lacking on sleep

Not getting enough sleep is physically (and often mentally) stressful. I knew an oceanography professor who had to harvest samples at sea, sometimes for days at a time, on no sleep.  The longer he went without sleeping, the higher his insulin resistance became. Lack of sleep may be causing some of your unexplained highs since more cortisol (a stress hormone) is released when you are sleep-deprived.

  • If you’ve had some alcohol to drink

Alcohol interferes with the normal function of the liver in making and releasing glucose. While it can lead to hypos, it can also be used strategically to relieve insulin resistance or to keep it in check—and luckily it does not take much alcohol to have an effect. An older guy called me on a diabetes hotline I was manning for a TV station once and explained that he usually had two shots of whiskey at night and woke up with good blood glucose levels, but that if he ever had to skip the whiskey, he would wake up too high.  He wanted to know what he should do.  I said, “Keep drinking the whiskey!” No more than one drink daily for women or two for men is recommended, though, so do not overdo it or you raise your risk of other health problems.

  • If it’s a certain time of the month (women only)

You may have everything else accounted for and your blood glucose levels are still skyrocketing for apparently no reason—except that you’re either ovulating (and releasing extra hormones that promote insulin resistance) or in the few days or week leading up to your period when insulin resistance is highest.  This has been a bigger issue for me later in life since my cycles seem to be more extreme, although I do not know if this is the case for all women. I helped a diabetes educator recently figure out that she was pregnant when she simply could not figure out why her blood glucose levels were so whacked out; it can be as simple an explanation as that (and hopefully a desired one, if pregnant).

Regardless of what is causing your (unexplained) insulin resistance, just try to manage your blood glucose levels the best you can and lose the guilt over not knowing exactly why it is high and not being totally in control 24/7. Even the most knowledgeable of us have our head-scratching and/or hair-pulling days trying to figure it out!

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)

How to Be the Biggest Maintainer, Not Just the Biggest Loser

Biggest maintainer

A study in Obesity in May 2016 (1) reported very discouraging findings for a group of participants who had lost weight on “The Biggest Loser” (TBL) reality TV show: not only did almost all of them regain a significant amount of weight over the 6-year period afterwards, but they also had lower resting metabolic rates than expected for their body weights, even six years later. With media spin, it won’t be a surprise if everyone just gives up staying thinner and blames excess weight on a faulty, and unchangeable, metabolism.

However, there are a number of factors that impact body weight and weight regain after loss, not just resting metabolism. How much physical activity people do daily and what type, the types of food that people eat, how many calories they actually ingest daily and when they consume them, stress management, and sleep patterns also have an impact on weight maintenance and regain after loss, among other things.

My issues with this study and with TBL’s approach to weight loss are the following:

(1) The way the contestants go about losing large amounts of body weight in a relatively short time is not sustainable as a lifestyle to maintain body weight after loss;

(2) Although TBL participants exercise (a whole lot) during their initial, six-month weight loss period—which helps prevent even greater losses of lean body mass than they would experience otherwise with such extreme weight loss—it does not prevent all muscle mass loss, which means that their total amount of muscle decreased (regardless of their relative ratios of fat and non-fat tissues);

(3) Dietary changes are as important to weight management as they are to weight loss, and diet is de-emphasized on TBL, with a focus instead on reality-TV- and entertainment-driven crazy amounts and types of physical activity; and

(4) TBL approach is not the same as that reported by successful losers and maintainers followed in the National Weight Control Registry (http://www.nwcr.ws).

With regard to that last point, much can be learned from studying members of the National Weight Control Registry (NWCR), which only includes people with medically documented weight losses of at least 30 pounds that were maintained for at least a year. While the members lost and keep the weight off in a variety of ways, most report continuing to maintain a low-calorie, low-fat diet and doing high levels of physical activity. Among the NWCR members: 78% eat breakfast every day; 75% weigh themselves at least once a week; 62% watch less than 10 hours of TV per week; and 90% exercise, on average, about 1 hour per day.

In one study, NWCR subjects spent significantly more time per day in sustained bouts of moderate-to-vigorous physical activity than their overweight counterparts (41.5 ± 35.1 min/day vs. 19.2 ± 18.6 min/day) and marginally more than normal weight adults (25.8 ± 23.4), so they were actually getting more daily exercise than most (2). A 10-year study of self-reported weight loss and behavior change in 2,886 NWCR participants (78% female; mean age 48 years), and more than 87% were still maintaining at least a 10% weight loss after five and ten years (3). Even though decreases in leisure-time physical activity, dietary restraint, and frequency of self-weighing, along with increases in percentage of energy intake from fat and disinhibition, were associated with greater weight regain, the majority of weight lost by NWCR members has been maintained over 10 years.

Others have reported that the differences in total weight gain in people being overfed similar amounts of calories was likely due to the total amount of daily movement that they engaged in, including standing, fidgeting, and taking more steps, not just planned exercise (4). Weight maintenance may, therefore, as influenced by total daily activity that is not necessarily reported or measured like most moderate and vigorous exercise is.

Weight maintenance may also be as simple as staying on top of body weight. NWCR studies have shown that consistent self-weighing may help individuals maintain their successful weight loss by allowing them to catch weight gains before they escalate and make behavior changes to prevent additional weight gain, and decreased self-weighing frequency is independently associated with greater weight regain (5).

Clearly, the body is a complex system with many different bodily and environmental factors adding to the mix. In the TBL study, there was no indication that they controlled for the potential effects of the last bout of exercise on resting metabolic measures (at least this was not reported on in the study), although exercise can impact metabolism for 2-72 hours afterwards They did not measure or report on the types of foods that the “biggest losers” were eating, although fiber is known to improve the gut microbiota and may be related to successful weight loss and maintenance (7). While many reported being active, doing cardio training versus resistance can have differing impacts on muscle glycogen storage, muscle mass, and insulin action, as well as resting metabolism, and the type of activity done was not reported in TBL study.

So, before we jump to any conclusions and blame all weight regain on something completely outside our control (a lower resting metabolism) and relinquish all personal responsibility for weight maintenance, make sure to consider all of the other potentially confounding variables that have not necessarily been well studied at this point. Let’s not just rely on and sensationalize the results of one small pilot study of “biggest losers,’ but rather take away lessons learned from the successful maintainers who are members of the much more reality-based NWCR.

Reference cited:

  1. Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD: Persistent metabolic adaptation 6 years after “the biggest loser” competition. Obesity 2016:n/a-n/a

Being Active and Getting Injured: How to Prevent This Conundrum

Back injury

You finally decide to get active to help manage your type 1 or type 2 diabetes better or to prevent type 2 altogether, and once you’ve hit your stride, you get an injury that puts you back on the couch! Getting injured from being active happens often enough that you need to know how to prevent and treat injuries so you can stay on track. The best medicine is prevention, so trying to prevent injuries before they happen is the best way to avoid having to take time off from exercising and sidetracking your fitness program. Here are some things you need to know:

The incidence of activity-related injuries, such as inflamed tendons (tendinitis) and stress fractures in bones, rises dramatically when people do more than 60 to 90 minutes of moderate or hard exercise daily. These types of overuse injury are nagging and persistently uncomfortable. Overuse injuries occur following excessive use the same joints and muscle in a similar way over an extended period of weeks or months. If you develop an overuse injury, it’s likely to be the result of excessive training, or doing too much too soon. In my own experience (since I’ve been regularly active for decades), they can also arise from doing something unusual, such as putting down a paver driveway, beating the yard into submission, or cleaning excessively prior to putting the house on the market.

Overuse injuries are more common in anyone with diabetes because elevated blood glucose can affect the health of your joints. Although everyone gets stiffer with age, diabetes accelerates the usual loss of flexibility especially when blood glucose is higher. Glucose “sticking” to joint surfaces makes people with diabetes more prone to overuse injuries like tendinitis and frozen shoulder (1; 2). It may also take longer for joint injuries to heal properly. The bones themselves can be thinned by exposure to elevated blood glucose levels, making fractures more common in people with any type of diabetes (3). The best prevention of any of these issues is optimal blood glucose control and regular stretching to maintain motion around joints.

You’ll likely benefit from doing a variety of activities on a weekly basis, an approach known as cross-training. Changing up your workouts is really they key to avoiding overuse injuries, keeping exercise fresh and fun, and getting more fit. Each activity a person does stresses muscles and joints differently, which lowers the risk of injury. It adds variety to an exercise program when you include activities like walking, cycling, rowing, swimming, arm biking, weight training, aerobic classes, and yoga, and it gives you the flexibility to choose different options based on your time constraints, the weather, and other factors. It also allows you to rest some muscles and joints without stopping exercising entirely. Alternating hard and easy days to lower the constant stress on muscles and joints is also a great idea.

To prevent overuse injuries, progress your exercise slowly (particularly the intensity), choose safe activities for you personally, always warm up and cool down, and make sure that you stretch your muscles regularly to stay more limber. For ongoing problems, treat affected areas with R.I.C.E. (rest, ice, compression, and elevation), combined with anti-inflammatory medications like ibuprofen (Advil or Nuprin) or naproxen sodium (found in Aleve), and avoid going back to normal activities or aggravating joints further until your symptoms resolve.

Finally, taking at least one day a week off from planned activities to rest allows your body time to recuperate and may prevent overuse injuries like tendinitis and stress fractures. It doesn’t mean that you have to stop moving, though, so keep your bodies in motion even on your days off for optimal blood glucose control.

References cited:

1. Abate M, Schiavone C, Pelotti P, Salini V: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2011;23:997-1003

2. Ranger TA, Wong AM, Cook JL, Gaida JE: Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med 2015;

3. McCabe L, Zhang J, Raehtz S: Understanding the skeletal pathology of type 1 and 2 diabetes mellitus. Crit Rev Eukaryot Gene Expr 2011;21:187-206