In people with type 1 diabetes, weight training before cardio exercise was linked with less severe drops in blood sugar.
MONDAY, Mar. 12, 2012 — It’s a question many workout devotees struggle with: weights before cardio, or vice versa? Now a new report says that for those with type 1 diabetes, it may be better to pump iron before getting on the elliptical or jogging around the block.
The study, published in the journal Diabetes Care, followed 12 active, young (average age 32) people with type 1 diabetes who were already running and doing strength training at least three times a week. In the first of two exercise sessions, the participants ran on a treadmill for 45 minutes, then lifted weights for 45 minutes. For the second session, the order was reversed (weights first, then running). Blood sugar levels were monitored before, during, and after each session.
The researchers found that when cardio was done first, glucose levels tended to drop and remain at low levels throughout the workout. By comparison, doing resistance exercise first was linked to less severe decreases in blood sugar, even hours after working out.
The study was small, and other factors that could have affected blood sugar were not considered. But according to Reuters Health, the findings agree with previous reports showing that aerobic workouts produce a quicker drop in blood sugar than strength training.
Balancing the health benefits of exercise with the risk of hypoglycemia (low blood sugar) can be tricky. During exercise, the body draws on blood glucose for energy — which can lead to those dangerous lows. Signs of hypoglycemia include dizziness, sweating, grumpiness, weakness, or hunger.
If you have type 1 diabetes and workout regularly, what else can you do to prevent low blood sugar besides switching around your exercise routine? The National Diabetes Information Clearinghouse recommends checking blood sugar first before exercising and having a snack if the level is below 100 milligrams per deciliter, as well as testing blood sugar at regular intervals both during an extended workout and after the session is completed. Wearing a medical identification bracelet and carrying food or glucose tablets during your workout are also smart ideas.
Showing posts with label diabetes and exercise. Show all posts
Showing posts with label diabetes and exercise. Show all posts
Wednesday, March 14, 2012
Wednesday, February 8, 2012
'Fat Chefs' and Diabetes: An Occupational Hazard?
Paula Deen's not alone. The new show 'Fat Chef' follows a dozen kitchen pros as they try to drop the pounds and reclaim their health.
FRIDAY, Jan. 27, 2012 — Have you ever heard the expression "Never trust a skinny chef?" Paula Deen isn't the only kitchen pro who's struggled with obesity — or with diabetes. Many men and women who make their living in the food industry, whether they're professional chefs, restauranteurs, caterers, or bakers, have issues with weight and compulsive eating. A new show, Fat Chef, which premiered on the Food Network this week, focuses on 12 of them as they embark on a 16-week plan to lose weight and get in shape.
One of the Fat Chef participants, 36-year-old Michael Mignano, is a bakery owner and pastry chef who was diagnosed with type 2 diabetes in 2009 after his weight reached 500 pounds. He told ABC News Nightline, "I allowed the stresses of work and life to just compound and just literally eat me alive," adding that when his blood sugar was finally checked by a doctor, it was "to the roof." But after four months eating lean protein and fiber and working out, Mignano has lost 100 pounds — going from a size 6X chef jacket down to a 2X. He also says he's "cured his diabetes" and hasn't taken any medication in three months.
Another Fat Chef participant, 41-year-old Ally Vitella, didn't know she had type 2 diabetes until she underwent a check-up for the show. Vitella, who weighed 345 pounds, says that her excess pounds affected her catering business, leaving her physically unable to carry equipment to her clients' locations. She told the Associated Press, "I was eating hors d'oeuvres for lunch and dinner. I would scoop up half a tray of food and eat it.…We cook things you're supposed to eat once in a while, but I was eating them every day." After doing the show, she's lost nearly 60 pounds and dropped from a size 28 to a size 16.
Another chef interviewed by the AP, Art Smith, was diagnosed with diabetes three years ago and says he reached 325 pounds on a diet of refined sugar and caffeine. Although he isn't one of the show participants, Smith, who was a former chef for Oprah Winfrey, has now lost 118 pounds and now runs marathons.
Mignano acknowledges the dangers of his chosen profession, telling the AP, "You have this abundance of food all around you…You're constantly tasting, working late hours, eating late." But the chef whose signature recipe is a "candy bar" loaded with caramel, nuts, and chocolate has no plans to find another line of work. "I love what I do, so for me to get another job and replace my profession is unfathomable," he told Nightline.
What can you do if you're surrounded by tempting, rich food all day long and need to watch your weight? One thing that may help is practicing mindful eating, which focuses on quieting the mind and tuning in to the body's hunger and fullness signals — both of which can stop that automatic hand-to-mouth motion. A recent study in the Journal of Nutrition and Education Behavior found that using mindful eating techniques when eating out helped women lose weight, even when they weren't trying to.
FRIDAY, Jan. 27, 2012 — Have you ever heard the expression "Never trust a skinny chef?" Paula Deen isn't the only kitchen pro who's struggled with obesity — or with diabetes. Many men and women who make their living in the food industry, whether they're professional chefs, restauranteurs, caterers, or bakers, have issues with weight and compulsive eating. A new show, Fat Chef, which premiered on the Food Network this week, focuses on 12 of them as they embark on a 16-week plan to lose weight and get in shape.
One of the Fat Chef participants, 36-year-old Michael Mignano, is a bakery owner and pastry chef who was diagnosed with type 2 diabetes in 2009 after his weight reached 500 pounds. He told ABC News Nightline, "I allowed the stresses of work and life to just compound and just literally eat me alive," adding that when his blood sugar was finally checked by a doctor, it was "to the roof." But after four months eating lean protein and fiber and working out, Mignano has lost 100 pounds — going from a size 6X chef jacket down to a 2X. He also says he's "cured his diabetes" and hasn't taken any medication in three months.
Another Fat Chef participant, 41-year-old Ally Vitella, didn't know she had type 2 diabetes until she underwent a check-up for the show. Vitella, who weighed 345 pounds, says that her excess pounds affected her catering business, leaving her physically unable to carry equipment to her clients' locations. She told the Associated Press, "I was eating hors d'oeuvres for lunch and dinner. I would scoop up half a tray of food and eat it.…We cook things you're supposed to eat once in a while, but I was eating them every day." After doing the show, she's lost nearly 60 pounds and dropped from a size 28 to a size 16.
Another chef interviewed by the AP, Art Smith, was diagnosed with diabetes three years ago and says he reached 325 pounds on a diet of refined sugar and caffeine. Although he isn't one of the show participants, Smith, who was a former chef for Oprah Winfrey, has now lost 118 pounds and now runs marathons.
Mignano acknowledges the dangers of his chosen profession, telling the AP, "You have this abundance of food all around you…You're constantly tasting, working late hours, eating late." But the chef whose signature recipe is a "candy bar" loaded with caramel, nuts, and chocolate has no plans to find another line of work. "I love what I do, so for me to get another job and replace my profession is unfathomable," he told Nightline.
What can you do if you're surrounded by tempting, rich food all day long and need to watch your weight? One thing that may help is practicing mindful eating, which focuses on quieting the mind and tuning in to the body's hunger and fullness signals — both of which can stop that automatic hand-to-mouth motion. A recent study in the Journal of Nutrition and Education Behavior found that using mindful eating techniques when eating out helped women lose weight, even when they weren't trying to.
Tuesday, November 8, 2011
EXERCISE AND NEUROPATHY: Not mutually exclusive
A classic case of innovative research turning conventional wisdom on its head is changing the way clinicians approach exercise in patients with diabetic neuropathy.
For decades, patients with type 2 diabetes and peripheral neuropathy were cautioned against weight-bearing exercise out of fear that the accompanying stress on the foot would lead to plantar ulcers. Then, in 2003, scientists began to report surprising findings.
“Prior to those studies, the feeling was that weight-bearing exercise was too risky to recommend to patients who lacked sensation,” said Joseph LeMaster, MD, MPH. LeMaster, for many years an associate professor in the Department of Family and Community Medicine at the University of Missouri, will move to the University of Kansas this fall. “There was evidence that people with neuropathy had increased plantar pressures, and those were considered an independent risk factor for foot ulcers.”
In 2003, LeMaster and his colleagues published a study of 400 diabetes patients with a history of foot ulcers and found that increased weight-bearing activity didn’t increase the risk of reulceration. Moreover, the most active subjects saw the most significant risk reduction, and the effects were the same regardless of whether subjects retained foot sensation.1
That same year, researchers from Washington University in St. Louis reported in Clinical Biomechanics that diabetes patients with a history of plantar ulcers were 46% less active and accumulated 41% less daily stress on the forefoot than nondiabetic and diabetic control subjects without a history of such ulcers.2 At first, the finding seemed so counterintuitive that people weren’t sure what to make of it. The authors ultimately concluded, conservatively, that subjects with a history of plantar ulcers were susceptible to injury at relatively low levels of tissue stress.
These studies flung open the door to further investigations, however. In 2004, scientists confirmed in Diabetes Care that neuropathic patients who exercised more had lower rates of ulceration than those who were relatively sedentary.3 Two years after that, in 2006, researchers in Italy reported that, far from being deleterious, exercise could help prevent neuropathy’s onset or modify its natural history.4 Right on cue, then, in 2008, Washington University researchers reporting on the Feet First study noted that promoting weight-bearing activity did not lead to significant increases in foot ulcers.5 Finally, in 2010, the American Diabetes Association, together with the American College of Sports Medicine, acknowledged this accumulating body of evidence and published new guidelines that, for the first time, endorsed weight-bearing exercise for patients with diabetic neuropathy in the absence of foot ulcers.6
“The new guidelines represent a big change,” said Michael Mueller, PT, PhD, a professor of physical therapy at Washington University School of Medicine. “For the first time, people with diabetic neuropathy are explicitly encouraged to do weight-bearing exercise.”
Although this rhythmic chronology outlines what appears to be a straightforward investigation that changed medical practice, the story is more nuanced. A number of questions have bedeviled researchers, and continue to. For example, what’s the chicken and what’s the egg? That is, do people get more ulcers because they get less exercise, or do they exercise less because of their ulcer history? Or, for that matter, are other variables involved that no one yet understands? These and other issues, such as how to distinguish those at highest risk of ulceration from their peers and how to adjust exercise regimens accordingly for individual patients, are only now starting to become clear.
Foundations
Back in 2002, Mueller published a paper in Physical Therapy whose relevance to this issue was not immediately clear, but which turned out to have a big impact. In that article, he proposed a “Physical Stress Theory” (PST) of tissue adaptation, the premise of which was that changes in the relative level of physical stress cause a predictable adaptive response in biological tissues.7 In a nutshell, the theory suggests that tissues respond to stress in predictable ways: stress levels that are too low lead to reduced stress tolerance and atrophy; mid-level stress produces no change; moderately high levels increase tolerance; and too much stress leads to injury and tissue death. The goal for practitioners seeking to increase their patients’ strength and resilience was to identify the levels that increased tolerance and work carefully from there.
Mueller also made several points that affected later researchers:
1. Stress exposure is a composite value comprising magnitude, time, and direction of stress application.
2. Extreme deviations from the maintenance stress range have serious consequences.
3. Individual stresses combine in complex ways to contribute to the overall level of stress exposure, and tissues are affected by the history of recent stresses.
4. Excessive stress can arise due to a brief, high-magnitude stress; a long duration of low-magnitude stress; or a repetitive application of moderate stress.
5. Inflammation occurs immediately after injury, reduces the injured tissue’s stress tolerance, and requires that the tissue be protected from further stress until the inflammation subsides.
Many of these points turned out to be crucial to understanding how to manage diabetic neuropathy in the context of exercise.
Variability
The lead author of the 2004 study in Diabetes Care was David Armstrong, DPM, MD, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson. An important aspect of his team’s findings was not just that more active subjects were less prone to ulcers, but that variability in activity was an important predictor of ulcer risk. Eight of 100 patients with diabetic neuropathy ulcerated during the average evaluation period of 37 weeks, and although they were significantly less active than those who remained ulcer-free, there was also much more variability in their exercise levels, as measured by high-capacity computerized accelerometer/pedometers.
“People who had wide swings in activity were at greater risk,” Armstrong told LER. “An example would be someone who’s not very active, then suddenly remembers their grandkid’s birthday and leaps off the couch, runs to the car, then spends an hour and a half walking around the mall. They do more in a couple of hours than they usually do in two days.”
When Armstrong and his colleagues first evaluated their data, they were flummoxed.
“We sat there wondering what was going on,” he said.
Their conclusion, however, echoed Mueller’s observations about the importance of tissue stress levels and the consequences of extreme deviation in them.
“We believe what we’re seeing is that it’s just like a lot of other places in the body,” Armstrong explained. “If you don’t use it, you lose it. If skin is allowed to atrophy, then maybe it’s weaker than skin that’s getting tenderized, as it were, by frequent activity.”
Armstrong noted that patients must be monitored carefully, as they were in his study, and that exercise has to be optimized for the individual.
“People can’t run a marathon with profound neuropathy, but we’d like to try to train them so they could slowly become more active,” he said. “We want to dose activity the way you’d titrate a drug.”
As for the chicken-and-egg problem—which comes first, the ulcer or the lower activity levels?—researchers are continuing to probe the reasons first ulcers appear. Manish Bharara, PhD, a research assistant professor at SALSA and a colleague of Armstrong’s, speculated that overall control of blood glucose levels may affect the resilience of damaged tissues.
“In diabetes patients, metabolic control affects other aspects of physiology, and could affect the quality of the tissue that is regenerated as someone heals,” he said.
A couple of Armstrong’s earlier papers may shed light on the issue, as well. In a 2001 article in the Journal of the American Podiatric Medical Association, Armstrong and his colleagues noted that diabetic patients with a history of neuropathy or ulceration took more steps per day inside the home than outside, and that only 15% of them wore their prescribed footwear inside.8 A paper in Diabetes Care in 2003 reported that subjects with foot ulcers wore their off-loading devices for only a minority of steps taken each day.9 Noncompliance with preventive footwear or curative devices could conceivably be similar in effect to low activity levels, then, in that both are associated with ulceration and poor healing. One possible explanation is that, compared to high-activity patients, low-activity patients are taking significantly fewer steps per day in footwear designed to help their feet avoid injury or heal (activity studies have not consistently reported compliance data).
“It even turns out that sometimes just standing for long periods can be potentially dangerous,” Armstrong noted.10 “This is all about better identifying risk and helping us better coach activity. We’re trying to get people moving, and in a lot of ways, that’s how we measure success.”
Individual cases
The Feet First study made it clear that clinicians must carefully consider the patient’s history when prescribing exercise, according to lead author LeMaster.
“In that study, we felt that the exercise program, combined with the careful monitoring we conducted, showed that the benefits of exercise outweighed the risks,” he said. “But it’s quite another thing to say that people who have lots of recent foot ulcers should go out and do this. A good percentage of the people in the study had had prior ulcers, and we didn’t find that to be a predictor [of ulceration during the trial]. But we restricted people from walking if they had any breakdown during the study.”
People with a history of frequent and recurrent ulcers, he added, should be viewed in a different category than those included in the research. Furthermore, the study’s subjects had their feet examined weekly by a physical therapist for the first three months, and had a hotline to call if they showed signs of ulceration later.
Mike Mueller, a coauthor of the 2008 Feet First paper, likened the evolving view of exercise in those with neuropathy to a similar evolution in thinking about exercise in cardiac patients a few decades ago.
“There was a time when the prevailing opinion was that if you’d had a heart attack, you should not exert yourself,” Mueller said. “We came to learn that if you monitor the heart carefully and keep it within a safe range, exercise is beneficial. It’s similar with the neuropathic foot, although we’re still learning what the guidelines should be.”
Adjusting exercise programs to the individual based on variables such as ulcer history is still an emerging field, he noted, and based both on the evidence provided by research and on clinical experience.
“I believe that once you’ve had a full-thickness ulcer, you’re in a whole different category,” he said. “Even a mild one sends up a red flag that you’d better watch this person. There’s so much heterogeneity in the group of people who have diabetes and neuropathy that the program really needs to be tailored to the individual.”
Joint biomechanics
Part of the problem with such tailoring is that only recently has research begun to describe the relationship between biomechanics and diabetic neuropathy.
For example, a 2007 paper in the Journal of Applied Biomechanics found that diabetic subjects with neuropathy had stiffer ankles than diabetic subjects without neuropathy.11 It’s known that normal mobility allows the foot to flexibly dissipate impact, then become rigid during push-off.12 Restricted mobility in the foot and ankle joints, then, could hinder this transition and contribute to abnormal plantar loads.13
Citing such evidence, Smita Rao, PhD, an assistant professor of physical therapy at New York University, published a paper in 2006 outlining how changes in muscle could account for decreased range of motion (ROM) and increased stiffness in patients with diabetes.14 In a subsequent article in Gait & Posture, she and her colleagues reported that decreased sagittal motion of the first metatarsal and lateral forefoot and frontal motion of the calcaneus were key elements that could contribute to increased, sustained plantar loading in patients with diabetes and neuropathy.15
“There’s a big push to emphasize exercise in patients with diabetes and peripheral neuropathy, but those patients are also at higher risk for tissue breakdown, so I wanted to explore the mechanisms that put them at risk,” Rao told LER. “We showed in the Gait & Posture paper that a lot of these patients try to reduce the effects of their stiffness by walking slower and taking shorter steps. When I examine them, I want to look at ankle range of motion, all the mechanical factors that may affect tissue breakdown; but I also want to assess how they walk, find focal regions of high pressure, then put those two together to see if walking is the best activity for this person. Some might need protective footwear, and some should ride a stationary bike instead.”
In her current research, Rao and her colleagues at NYU are examining ways to bring a number of fields together.
“My grandfather had diabetes, so I have a personal connection to the field,” she said. “All these negative effects begin with high blood sugar, so we’re trying to combine medical, surgical, and rehabilitative interventions in patients with diabetes and neuropathy.”
Exercise and balance
Other research has looked at the importance of augmenting exercise with balance training, which has been shown to improve clinical balance measures in neuropathic patients.16 A study published in Diabetes Care in 2010 demonstrated, moreover, that six weeks of such training reduced the risk of falls in 16 older patients with type 2 diabetes and mild to moderate neuropathy.17 In that research, exercise sessions included a balance/posture component (lower-limb stretches and leg, abdominal, and lower-back exercises) and a resistance and strength-training component using machines. The regimen led to better reaction times and affected sensory, motor, and cognitive processes, leading to a significant decline in risk of falls.
Lead author Steven Morrison, PhD, director of research in the School of Physical Therapy at Old Dominion University in Norfolk, VA, told LER that his group’s work was motivated partly by the fact that older diabetes patients’ risk of falling is 10 to 15 times that of healthy age-matched controls, which affects their confidence and ability to exercise.
“To be balanced, you need a certain amount of strength and a certain amount of coordination,” he said. “We found that after six weeks of training, type 2 diabetic individuals become more like the control group—there’s very little difference in terms of how much they sway and what their balance is like.”
Monitoring
David Sinacore, PT, PhD, a professor of physical therapy and medicine at Washington University, and one of the researchers involved in studies of exercise and neuropathy there, emphasized that monitoring—by clinicians or the patients themselves—is crucial to successful exercise programs in those with diabetic neuropathy, particularly if they also have foot deformities such as those resulting from Charcot arthropathy.
“I’m a firm believer that these folks need to exercise for their diabetes,” he said. “But if they start to develop lesions, they need to be addressed.”
Of course, as most clinicians know, there is often a gap between ideal and real-world monitoring levels.
“It’s hard for these patients to check the bottom of their feet regularly, so they sometimes don’t do it,” Sinacore said.
One way to help is with temperature monitoring. Sinacore recommends foot-temperature gauges that patients can use right after exercising, some of which are hook-shaped to ease plantar access.
“When we monitor them here, we check temperature before and after exercise,” he said. “We’re looking for hot spots and temperature differences that may indicate that they’re developing a lesion.”
In such cases, therapists recommend that patients decrease their exercise levels for a while and have their footwear modified to relieve pressure.
David Armstrong agreed that thermometry provides a way of keeping track of the damage caused by weight-bearing exercise.
“We want our patients to dose their activity by checking their skin temperature just as they dose their insulin by checking their glucose,” he said.
His colleague, Manish Bharara, conducts innovative research in this aspect of care.18
“In the last decade we’ve learned that a four-degree difference between two similar sites on both feet is an ulcer risk,” he said. “If the pattern persists over multiple days, the patient should reduce activity and immediately see a doctor.”
Bharara and his colleagues are developing a thermometry scale to address some of the inconveniences typically associated with measuring foot temperature at several sites. Patients stand on it—it’s similar to a bathroom scale—while it measures foot temperature at 20 sites on each foot and records the data. The scale speaks to the patient—telling him, for example, that his right big toe temperature is 5° warmer than the left. Moreover, if the scale detects an abnormal pattern for more than two days, it can be programmed to send a message to the physician’s office and make an appointment.
“Something like this could really help manage patients’ diabetes better, because the biggest barrier is compliance,” Bharara said.
New research
Other researchers are examining variables that affect neuropathic patients’ exercise capabilities, as well. For example, at the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University in Chicago, Bijan Najafi, PhD, associate professor of applied biomechanics, has studied factors including gait initiation in this context.19 As opposed to the measures of steady-state walking—such as rate or number of steps—typically used in exercise studies, a prolonged gait initiation phase (the period between upright posture and steady-state gait) may be associated with increased fall risk.
“During the initiation of the step, there’s an important acceleration phase, and it creates a lot of resistive force,” Najafi said. “We’ve found that neuropathy patients have longer gait initiation. This makes sense, because to reach steady-state gait, people have to gather somatosensory feedback to find the speed at which they can walk safely and minimize energy costs. Neuropathy patients have impaired somatosensory feedback, though. But we believe that if we can provide a good exercise to compensate, we may be able to improve the gait initiation phase.”
One way to help, Najafi thinks, is to take a cue from the dance world.
“If you’re trying to explain a movement problem to a dancer he may not get it, but if you put a mirror in front of him and show him the correct position of the joints, he can improve his motor skills,” he said. “The brain is plastic, and if it realizes there’s an error, it will try to minimize it next time. So we hope that by letting neuropathy patients observe their errors this way, they may improve their motor skills.”
Cary Groner is a freelance writer based in the San Francisco Bay Area.
For decades, patients with type 2 diabetes and peripheral neuropathy were cautioned against weight-bearing exercise out of fear that the accompanying stress on the foot would lead to plantar ulcers. Then, in 2003, scientists began to report surprising findings.
“Prior to those studies, the feeling was that weight-bearing exercise was too risky to recommend to patients who lacked sensation,” said Joseph LeMaster, MD, MPH. LeMaster, for many years an associate professor in the Department of Family and Community Medicine at the University of Missouri, will move to the University of Kansas this fall. “There was evidence that people with neuropathy had increased plantar pressures, and those were considered an independent risk factor for foot ulcers.”
In 2003, LeMaster and his colleagues published a study of 400 diabetes patients with a history of foot ulcers and found that increased weight-bearing activity didn’t increase the risk of reulceration. Moreover, the most active subjects saw the most significant risk reduction, and the effects were the same regardless of whether subjects retained foot sensation.1
That same year, researchers from Washington University in St. Louis reported in Clinical Biomechanics that diabetes patients with a history of plantar ulcers were 46% less active and accumulated 41% less daily stress on the forefoot than nondiabetic and diabetic control subjects without a history of such ulcers.2 At first, the finding seemed so counterintuitive that people weren’t sure what to make of it. The authors ultimately concluded, conservatively, that subjects with a history of plantar ulcers were susceptible to injury at relatively low levels of tissue stress.
These studies flung open the door to further investigations, however. In 2004, scientists confirmed in Diabetes Care that neuropathic patients who exercised more had lower rates of ulceration than those who were relatively sedentary.3 Two years after that, in 2006, researchers in Italy reported that, far from being deleterious, exercise could help prevent neuropathy’s onset or modify its natural history.4 Right on cue, then, in 2008, Washington University researchers reporting on the Feet First study noted that promoting weight-bearing activity did not lead to significant increases in foot ulcers.5 Finally, in 2010, the American Diabetes Association, together with the American College of Sports Medicine, acknowledged this accumulating body of evidence and published new guidelines that, for the first time, endorsed weight-bearing exercise for patients with diabetic neuropathy in the absence of foot ulcers.6
“The new guidelines represent a big change,” said Michael Mueller, PT, PhD, a professor of physical therapy at Washington University School of Medicine. “For the first time, people with diabetic neuropathy are explicitly encouraged to do weight-bearing exercise.”
Although this rhythmic chronology outlines what appears to be a straightforward investigation that changed medical practice, the story is more nuanced. A number of questions have bedeviled researchers, and continue to. For example, what’s the chicken and what’s the egg? That is, do people get more ulcers because they get less exercise, or do they exercise less because of their ulcer history? Or, for that matter, are other variables involved that no one yet understands? These and other issues, such as how to distinguish those at highest risk of ulceration from their peers and how to adjust exercise regimens accordingly for individual patients, are only now starting to become clear.
Foundations
Back in 2002, Mueller published a paper in Physical Therapy whose relevance to this issue was not immediately clear, but which turned out to have a big impact. In that article, he proposed a “Physical Stress Theory” (PST) of tissue adaptation, the premise of which was that changes in the relative level of physical stress cause a predictable adaptive response in biological tissues.7 In a nutshell, the theory suggests that tissues respond to stress in predictable ways: stress levels that are too low lead to reduced stress tolerance and atrophy; mid-level stress produces no change; moderately high levels increase tolerance; and too much stress leads to injury and tissue death. The goal for practitioners seeking to increase their patients’ strength and resilience was to identify the levels that increased tolerance and work carefully from there.
Mueller also made several points that affected later researchers:
1. Stress exposure is a composite value comprising magnitude, time, and direction of stress application.
2. Extreme deviations from the maintenance stress range have serious consequences.
3. Individual stresses combine in complex ways to contribute to the overall level of stress exposure, and tissues are affected by the history of recent stresses.
4. Excessive stress can arise due to a brief, high-magnitude stress; a long duration of low-magnitude stress; or a repetitive application of moderate stress.
5. Inflammation occurs immediately after injury, reduces the injured tissue’s stress tolerance, and requires that the tissue be protected from further stress until the inflammation subsides.
Many of these points turned out to be crucial to understanding how to manage diabetic neuropathy in the context of exercise.
Variability
The lead author of the 2004 study in Diabetes Care was David Armstrong, DPM, MD, PhD, professor of surgery and director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson. An important aspect of his team’s findings was not just that more active subjects were less prone to ulcers, but that variability in activity was an important predictor of ulcer risk. Eight of 100 patients with diabetic neuropathy ulcerated during the average evaluation period of 37 weeks, and although they were significantly less active than those who remained ulcer-free, there was also much more variability in their exercise levels, as measured by high-capacity computerized accelerometer/pedometers.
“People who had wide swings in activity were at greater risk,” Armstrong told LER. “An example would be someone who’s not very active, then suddenly remembers their grandkid’s birthday and leaps off the couch, runs to the car, then spends an hour and a half walking around the mall. They do more in a couple of hours than they usually do in two days.”
When Armstrong and his colleagues first evaluated their data, they were flummoxed.
“We sat there wondering what was going on,” he said.
Their conclusion, however, echoed Mueller’s observations about the importance of tissue stress levels and the consequences of extreme deviation in them.
“We believe what we’re seeing is that it’s just like a lot of other places in the body,” Armstrong explained. “If you don’t use it, you lose it. If skin is allowed to atrophy, then maybe it’s weaker than skin that’s getting tenderized, as it were, by frequent activity.”
Armstrong noted that patients must be monitored carefully, as they were in his study, and that exercise has to be optimized for the individual.
“People can’t run a marathon with profound neuropathy, but we’d like to try to train them so they could slowly become more active,” he said. “We want to dose activity the way you’d titrate a drug.”
As for the chicken-and-egg problem—which comes first, the ulcer or the lower activity levels?—researchers are continuing to probe the reasons first ulcers appear. Manish Bharara, PhD, a research assistant professor at SALSA and a colleague of Armstrong’s, speculated that overall control of blood glucose levels may affect the resilience of damaged tissues.
“In diabetes patients, metabolic control affects other aspects of physiology, and could affect the quality of the tissue that is regenerated as someone heals,” he said.
A couple of Armstrong’s earlier papers may shed light on the issue, as well. In a 2001 article in the Journal of the American Podiatric Medical Association, Armstrong and his colleagues noted that diabetic patients with a history of neuropathy or ulceration took more steps per day inside the home than outside, and that only 15% of them wore their prescribed footwear inside.8 A paper in Diabetes Care in 2003 reported that subjects with foot ulcers wore their off-loading devices for only a minority of steps taken each day.9 Noncompliance with preventive footwear or curative devices could conceivably be similar in effect to low activity levels, then, in that both are associated with ulceration and poor healing. One possible explanation is that, compared to high-activity patients, low-activity patients are taking significantly fewer steps per day in footwear designed to help their feet avoid injury or heal (activity studies have not consistently reported compliance data).
“It even turns out that sometimes just standing for long periods can be potentially dangerous,” Armstrong noted.10 “This is all about better identifying risk and helping us better coach activity. We’re trying to get people moving, and in a lot of ways, that’s how we measure success.”
Individual cases
The Feet First study made it clear that clinicians must carefully consider the patient’s history when prescribing exercise, according to lead author LeMaster.
“In that study, we felt that the exercise program, combined with the careful monitoring we conducted, showed that the benefits of exercise outweighed the risks,” he said. “But it’s quite another thing to say that people who have lots of recent foot ulcers should go out and do this. A good percentage of the people in the study had had prior ulcers, and we didn’t find that to be a predictor [of ulceration during the trial]. But we restricted people from walking if they had any breakdown during the study.”
People with a history of frequent and recurrent ulcers, he added, should be viewed in a different category than those included in the research. Furthermore, the study’s subjects had their feet examined weekly by a physical therapist for the first three months, and had a hotline to call if they showed signs of ulceration later.
Mike Mueller, a coauthor of the 2008 Feet First paper, likened the evolving view of exercise in those with neuropathy to a similar evolution in thinking about exercise in cardiac patients a few decades ago.
“There was a time when the prevailing opinion was that if you’d had a heart attack, you should not exert yourself,” Mueller said. “We came to learn that if you monitor the heart carefully and keep it within a safe range, exercise is beneficial. It’s similar with the neuropathic foot, although we’re still learning what the guidelines should be.”
Adjusting exercise programs to the individual based on variables such as ulcer history is still an emerging field, he noted, and based both on the evidence provided by research and on clinical experience.
“I believe that once you’ve had a full-thickness ulcer, you’re in a whole different category,” he said. “Even a mild one sends up a red flag that you’d better watch this person. There’s so much heterogeneity in the group of people who have diabetes and neuropathy that the program really needs to be tailored to the individual.”
Joint biomechanics
Part of the problem with such tailoring is that only recently has research begun to describe the relationship between biomechanics and diabetic neuropathy.
For example, a 2007 paper in the Journal of Applied Biomechanics found that diabetic subjects with neuropathy had stiffer ankles than diabetic subjects without neuropathy.11 It’s known that normal mobility allows the foot to flexibly dissipate impact, then become rigid during push-off.12 Restricted mobility in the foot and ankle joints, then, could hinder this transition and contribute to abnormal plantar loads.13
Citing such evidence, Smita Rao, PhD, an assistant professor of physical therapy at New York University, published a paper in 2006 outlining how changes in muscle could account for decreased range of motion (ROM) and increased stiffness in patients with diabetes.14 In a subsequent article in Gait & Posture, she and her colleagues reported that decreased sagittal motion of the first metatarsal and lateral forefoot and frontal motion of the calcaneus were key elements that could contribute to increased, sustained plantar loading in patients with diabetes and neuropathy.15
“There’s a big push to emphasize exercise in patients with diabetes and peripheral neuropathy, but those patients are also at higher risk for tissue breakdown, so I wanted to explore the mechanisms that put them at risk,” Rao told LER. “We showed in the Gait & Posture paper that a lot of these patients try to reduce the effects of their stiffness by walking slower and taking shorter steps. When I examine them, I want to look at ankle range of motion, all the mechanical factors that may affect tissue breakdown; but I also want to assess how they walk, find focal regions of high pressure, then put those two together to see if walking is the best activity for this person. Some might need protective footwear, and some should ride a stationary bike instead.”
In her current research, Rao and her colleagues at NYU are examining ways to bring a number of fields together.
“My grandfather had diabetes, so I have a personal connection to the field,” she said. “All these negative effects begin with high blood sugar, so we’re trying to combine medical, surgical, and rehabilitative interventions in patients with diabetes and neuropathy.”
Exercise and balance
Other research has looked at the importance of augmenting exercise with balance training, which has been shown to improve clinical balance measures in neuropathic patients.16 A study published in Diabetes Care in 2010 demonstrated, moreover, that six weeks of such training reduced the risk of falls in 16 older patients with type 2 diabetes and mild to moderate neuropathy.17 In that research, exercise sessions included a balance/posture component (lower-limb stretches and leg, abdominal, and lower-back exercises) and a resistance and strength-training component using machines. The regimen led to better reaction times and affected sensory, motor, and cognitive processes, leading to a significant decline in risk of falls.
Lead author Steven Morrison, PhD, director of research in the School of Physical Therapy at Old Dominion University in Norfolk, VA, told LER that his group’s work was motivated partly by the fact that older diabetes patients’ risk of falling is 10 to 15 times that of healthy age-matched controls, which affects their confidence and ability to exercise.
“To be balanced, you need a certain amount of strength and a certain amount of coordination,” he said. “We found that after six weeks of training, type 2 diabetic individuals become more like the control group—there’s very little difference in terms of how much they sway and what their balance is like.”
Monitoring
David Sinacore, PT, PhD, a professor of physical therapy and medicine at Washington University, and one of the researchers involved in studies of exercise and neuropathy there, emphasized that monitoring—by clinicians or the patients themselves—is crucial to successful exercise programs in those with diabetic neuropathy, particularly if they also have foot deformities such as those resulting from Charcot arthropathy.
“I’m a firm believer that these folks need to exercise for their diabetes,” he said. “But if they start to develop lesions, they need to be addressed.”
Of course, as most clinicians know, there is often a gap between ideal and real-world monitoring levels.
“It’s hard for these patients to check the bottom of their feet regularly, so they sometimes don’t do it,” Sinacore said.
One way to help is with temperature monitoring. Sinacore recommends foot-temperature gauges that patients can use right after exercising, some of which are hook-shaped to ease plantar access.
“When we monitor them here, we check temperature before and after exercise,” he said. “We’re looking for hot spots and temperature differences that may indicate that they’re developing a lesion.”
In such cases, therapists recommend that patients decrease their exercise levels for a while and have their footwear modified to relieve pressure.
David Armstrong agreed that thermometry provides a way of keeping track of the damage caused by weight-bearing exercise.
“We want our patients to dose their activity by checking their skin temperature just as they dose their insulin by checking their glucose,” he said.
His colleague, Manish Bharara, conducts innovative research in this aspect of care.18
“In the last decade we’ve learned that a four-degree difference between two similar sites on both feet is an ulcer risk,” he said. “If the pattern persists over multiple days, the patient should reduce activity and immediately see a doctor.”
Bharara and his colleagues are developing a thermometry scale to address some of the inconveniences typically associated with measuring foot temperature at several sites. Patients stand on it—it’s similar to a bathroom scale—while it measures foot temperature at 20 sites on each foot and records the data. The scale speaks to the patient—telling him, for example, that his right big toe temperature is 5° warmer than the left. Moreover, if the scale detects an abnormal pattern for more than two days, it can be programmed to send a message to the physician’s office and make an appointment.
“Something like this could really help manage patients’ diabetes better, because the biggest barrier is compliance,” Bharara said.
New research
Other researchers are examining variables that affect neuropathic patients’ exercise capabilities, as well. For example, at the Center for Lower Extremity Ambulatory Research at Rosalind Franklin University in Chicago, Bijan Najafi, PhD, associate professor of applied biomechanics, has studied factors including gait initiation in this context.19 As opposed to the measures of steady-state walking—such as rate or number of steps—typically used in exercise studies, a prolonged gait initiation phase (the period between upright posture and steady-state gait) may be associated with increased fall risk.
“During the initiation of the step, there’s an important acceleration phase, and it creates a lot of resistive force,” Najafi said. “We’ve found that neuropathy patients have longer gait initiation. This makes sense, because to reach steady-state gait, people have to gather somatosensory feedback to find the speed at which they can walk safely and minimize energy costs. Neuropathy patients have impaired somatosensory feedback, though. But we believe that if we can provide a good exercise to compensate, we may be able to improve the gait initiation phase.”
One way to help, Najafi thinks, is to take a cue from the dance world.
“If you’re trying to explain a movement problem to a dancer he may not get it, but if you put a mirror in front of him and show him the correct position of the joints, he can improve his motor skills,” he said. “The brain is plastic, and if it realizes there’s an error, it will try to minimize it next time. So we hope that by letting neuropathy patients observe their errors this way, they may improve their motor skills.”
Cary Groner is a freelance writer based in the San Francisco Bay Area.
Friday, September 9, 2011
More Muscle Mass Knocks Out Insulin Resistance and Prediabetes
Having more muscle mass can protect against insulin resistance and prediabetes, no matter overall body size, researchers said....
In a cross-sectional study, every 10% increase in the ratio of skeletal muscle mass to total body weight was associated with an 11% reduction in risk of insulin resistance and a 12% drop in risk of transitional, prediabetes, or overt diabetes. The findings point to the importance of gauging muscle mass, in addition to other established risk factors such as body mass index (BMI) and waist circumference, when assessing a patient's metabolic health, the researchers said.
The results may also have implications for the role of muscle-building exercises in preventing metabolic dysfunction.
It's known that very low muscle mass (sarcopenia) is a risk factor for insulin resistance, but it's unclear whether increasing muscle mass outside of the sarcopenic range can boost insulin sensitivity or protect against diabetes.
So to determine whether increases in muscle mass are associated with improved glucose regulation, the researchers looked at data on 13,644 patients from the National Health and Nutrition Examination Survey (NHANES) III, conducted from 1988 to 1994.
Patients had data on homeostasis model assessment of insulin resistance (HOMA-IR); glycated hemoglobin (HbA1c); prevalence of transitional, prediabetes, or overt diabetes (PMD); and prevalence of overt diabetes mellitus. These four factors served as the study outcomes.
Muscle mass was assessed via bioelectrical impedance, which measures opposition to the flow of an electric current through body tissues, determining total body water to estimate body composition.
The researchers found that all four of the outcomes declined across quartiles from lowest to highest skeletal muscle index, or the ratio of skeletal muscle to body weight. The smallest effect size was seen for HbA1c, with a 5.8% relative mean reduction between the highest and lowest quartiles.
On the other hand, the most striking effect was in diabetes prevalence, with a relative reduction of 63%. Prevalence was 14.5% in the lowest quartile compared with only 5.3% in the highest, the researchers reported.
After adjusting for confounders including age, ethnicity, sex, and obesity, the relationships persisted for insulin resistance and prevalence of transitional, prediabetes, and overt diabetes.
Specifically, each 10% increase in skeletal muscle index was associated with 11% relative reduction in HOMA-IR and a 12% relative reduction in the combined diabetes endpoint.
After excluding patients with diabetes, these relationships were strengthened. For every 10% increase in muscle mass ratio, there was a 14% reduction in HOMA-IR and a 23% reduction in combined diabetes prevalence.
They explained that the weaker associations when diabetic patients were included were likely due to the effects of diabetes on muscle mass and on pancreatic beta-cell mass.
The researchers concluded that the relationship between muscle mass and insulin resistance was not limited to sarcopenia, as "increases in muscle mass above even average levels were associated with additional protection against insulin resistance and prediabetes."
The study was limited by its cross-sectional nature, and by its use of bioelectrical impedance alone to estimate muscle mass. Also, there was no differentiation between type 1 and type 2 diabetes in the original survey, they said.
As well, patients with high muscle mass tend to have low fat mass, so any of the associations may be due to adipose tissue, they cautioned, although they attempted to control for this.
Despite these findings, prior prospective studies of short-term strength training programs in overweight and obese patients have been unclear in terms of their effects on metabolic abnormalities, they said.
They called for more work to determine the proper duration of exercise interventions needed in order to improve insulin sensitivity and glucose metabolism, and ultimately to have an effect on diabetes incidence.
In a cross-sectional study, every 10% increase in the ratio of skeletal muscle mass to total body weight was associated with an 11% reduction in risk of insulin resistance and a 12% drop in risk of transitional, prediabetes, or overt diabetes. The findings point to the importance of gauging muscle mass, in addition to other established risk factors such as body mass index (BMI) and waist circumference, when assessing a patient's metabolic health, the researchers said.
The results may also have implications for the role of muscle-building exercises in preventing metabolic dysfunction.
It's known that very low muscle mass (sarcopenia) is a risk factor for insulin resistance, but it's unclear whether increasing muscle mass outside of the sarcopenic range can boost insulin sensitivity or protect against diabetes.
So to determine whether increases in muscle mass are associated with improved glucose regulation, the researchers looked at data on 13,644 patients from the National Health and Nutrition Examination Survey (NHANES) III, conducted from 1988 to 1994.
Patients had data on homeostasis model assessment of insulin resistance (HOMA-IR); glycated hemoglobin (HbA1c); prevalence of transitional, prediabetes, or overt diabetes (PMD); and prevalence of overt diabetes mellitus. These four factors served as the study outcomes.
Muscle mass was assessed via bioelectrical impedance, which measures opposition to the flow of an electric current through body tissues, determining total body water to estimate body composition.
The researchers found that all four of the outcomes declined across quartiles from lowest to highest skeletal muscle index, or the ratio of skeletal muscle to body weight. The smallest effect size was seen for HbA1c, with a 5.8% relative mean reduction between the highest and lowest quartiles.
On the other hand, the most striking effect was in diabetes prevalence, with a relative reduction of 63%. Prevalence was 14.5% in the lowest quartile compared with only 5.3% in the highest, the researchers reported.
After adjusting for confounders including age, ethnicity, sex, and obesity, the relationships persisted for insulin resistance and prevalence of transitional, prediabetes, and overt diabetes.
Specifically, each 10% increase in skeletal muscle index was associated with 11% relative reduction in HOMA-IR and a 12% relative reduction in the combined diabetes endpoint.
After excluding patients with diabetes, these relationships were strengthened. For every 10% increase in muscle mass ratio, there was a 14% reduction in HOMA-IR and a 23% reduction in combined diabetes prevalence.
They explained that the weaker associations when diabetic patients were included were likely due to the effects of diabetes on muscle mass and on pancreatic beta-cell mass.
The researchers concluded that the relationship between muscle mass and insulin resistance was not limited to sarcopenia, as "increases in muscle mass above even average levels were associated with additional protection against insulin resistance and prediabetes."
The study was limited by its cross-sectional nature, and by its use of bioelectrical impedance alone to estimate muscle mass. Also, there was no differentiation between type 1 and type 2 diabetes in the original survey, they said.
As well, patients with high muscle mass tend to have low fat mass, so any of the associations may be due to adipose tissue, they cautioned, although they attempted to control for this.
Despite these findings, prior prospective studies of short-term strength training programs in overweight and obese patients have been unclear in terms of their effects on metabolic abnormalities, they said.
They called for more work to determine the proper duration of exercise interventions needed in order to improve insulin sensitivity and glucose metabolism, and ultimately to have an effect on diabetes incidence.
Sunday, June 12, 2011
Broccoli Sprouts Have Benefits for Diabetes Patients
Broccoli sprouts may boost antioxidant defenses in people with diabetes....
According to findings, a daily dose of five or 10 grams of the broccoli sprout powder was associated with an increase in the total antioxidant capacity of the blood, and reductions in malondialdehyde (MDA), a reactive carbonyl compound and a well-established marker of oxidative stress. The study adds to the growing body of science supporting the potential health benefits of broccoli and broccoli sprouts, most often touted for their potential anti-cancer activity.
The tissue of cruciferous vegetables, like broccoli, cauliflower, cabbage and Brussels sprouts, contain high levels of the active plant chemicals glucosinolates. These are metabolized by the body into isothiocyanates, which are known to be antioxidants and powerful anti-carcinogens. The main isothiocyanate from broccoli is sulphoraphane.
The new study employed a broccoli sprout powder that provided a dose of sulphoraphane isothiocyanates of 22.5 micromoles per gram, and looked at the potential antioxidant activity of broccoli sprout powder to counter oxidative stress in diabetics.
Oxygen-breathing organisms naturally produce reactive oxygen species (ROS), which play an important role in a range of functions, including cell signaling. However, over production of these ROS from smoking, pollution, sunlight, high intensity exercise, or simply ageing, may overwhelm the body's antioxidant defenses and lead to oxidative stress.
Oxidative stress has been linked to an increased risk of various diseases including cancer, Alzheimer's, and cardiovascular disease.
Researchers also note that oxidative stress is a key driver in the onset of insulin resistance, which ultimately leads to diabetes. Diabetes itself is associated with increased levels of oxidative stress, and this can promote the development of diabetes-related complications
Researchers from the National Nutrition and Food Technology Research Institute at the Shahid Beheshti University of Medical Sciences in Tehran, Iran, recruited 81 diabetics to participate in their double-blind, placebo-controlled, randomized clinical trial.
Participants were randomly assigned to receive either five or 10 grams per day of the broccoli sprout powder, or placebo, for four weeks.
Results showed that both broccoli groups experienced significant decreases in MDA, a well-established marker of oxidative stress, as well as reductions in levels of oxidized LDL cholesterol, another oxidative stress marker.
The doses used in this study provided 225 micromoles and 112 micromoles sulforaphane isothiocyanates daily per 10 g and 5 g broccoli sprout doses, respectively.
European Journal of Clinical Nutrition; "Broccoli sprouts reduce oxidative stress in type 2 diabetes: a randomized double-blind clinical trial" Z Bahadoran, P Mirmira, et al
According to findings, a daily dose of five or 10 grams of the broccoli sprout powder was associated with an increase in the total antioxidant capacity of the blood, and reductions in malondialdehyde (MDA), a reactive carbonyl compound and a well-established marker of oxidative stress. The study adds to the growing body of science supporting the potential health benefits of broccoli and broccoli sprouts, most often touted for their potential anti-cancer activity.
The tissue of cruciferous vegetables, like broccoli, cauliflower, cabbage and Brussels sprouts, contain high levels of the active plant chemicals glucosinolates. These are metabolized by the body into isothiocyanates, which are known to be antioxidants and powerful anti-carcinogens. The main isothiocyanate from broccoli is sulphoraphane.
The new study employed a broccoli sprout powder that provided a dose of sulphoraphane isothiocyanates of 22.5 micromoles per gram, and looked at the potential antioxidant activity of broccoli sprout powder to counter oxidative stress in diabetics.
Oxygen-breathing organisms naturally produce reactive oxygen species (ROS), which play an important role in a range of functions, including cell signaling. However, over production of these ROS from smoking, pollution, sunlight, high intensity exercise, or simply ageing, may overwhelm the body's antioxidant defenses and lead to oxidative stress.
Oxidative stress has been linked to an increased risk of various diseases including cancer, Alzheimer's, and cardiovascular disease.
Researchers also note that oxidative stress is a key driver in the onset of insulin resistance, which ultimately leads to diabetes. Diabetes itself is associated with increased levels of oxidative stress, and this can promote the development of diabetes-related complications
Researchers from the National Nutrition and Food Technology Research Institute at the Shahid Beheshti University of Medical Sciences in Tehran, Iran, recruited 81 diabetics to participate in their double-blind, placebo-controlled, randomized clinical trial.
Participants were randomly assigned to receive either five or 10 grams per day of the broccoli sprout powder, or placebo, for four weeks.
Results showed that both broccoli groups experienced significant decreases in MDA, a well-established marker of oxidative stress, as well as reductions in levels of oxidized LDL cholesterol, another oxidative stress marker.
The doses used in this study provided 225 micromoles and 112 micromoles sulforaphane isothiocyanates daily per 10 g and 5 g broccoli sprout doses, respectively.
European Journal of Clinical Nutrition; "Broccoli sprouts reduce oxidative stress in type 2 diabetes: a randomized double-blind clinical trial" Z Bahadoran, P Mirmira, et al
Friday, April 22, 2011
Controlling Diabetes With Exercise
Exercise can be an effective way to get your blood sugar under control. Get motivated to start — and stick to — an exercise plan.
By Krisha McCoy, MS
Medically reviewed by Pat F. Bass III, MD, MPH Print Email Exercise is important for everyone, but it can be especially important for your health if you have diabetes. People who exercise regularly are better able to control their diabetes, thereby reducing their risk of diabetes complications.
Diabetes and Exercise: Why It’s Important to Stay Fit
If you have diabetes, you have an increased risk of developing certain health conditions, including heart attack, stroke, kidney disease, and nerve problems. By following your doctor's recommendations for keeping your blood glucose levels under control, you can reduce your risk of developing these complications.
Researchers have found that people who exercise regularly have:
Lower blood glucose levels
Lower blood pressure
Better cholesterol levels
Improved ability to use insulin
Decreased risk of stroke
Decreased risk of heart diseaseStronger bones
Less chance of falling
Easier weight loss
Less body fat
More energy
Reduced stress levels
In addition, if you use insulin to treat your diabetes, exercise can be part of the daily schedule that you and your diabetes health care team develop to control your blood glucose levels.
Diabetes and Exercise: Getting Started
Talk with your diabetes health care team before you begin an exercise program. They can help you design an exercise program that is safe and effective for you. Make sure to ask about any limitations. If you have heart disease, kidney disease, eye problems, or foot problems, there may be some physical activities that you should not do.
To get started with an exercise program:
Find physical activities you like. Choose activities that you enjoy doing and that are convenient. Try new activities, such as walking, dancing, swimming, or bicycling, until you find one you like.Schedule your workouts. Make exercise part of your schedule, just like work and doctor appointments. Aim to work out for at least half an hour on most or all days of the week.Slowly increase your time and intensity. Don't start out doing too much, or you may get burned out. Begin with just a few minutes, and add a little time, distance, or intensity to your workouts each week.Find an exercise partner. Ask a friend or neighbor to join you in your exercise plan. For many people, having a person who is counting on you will make you less likely to skip a workout. Keep a workout journal. Each time you exercise, write down what you did and what your blood glucose levels were. That way you can keep track of your progress and see how activity affects your diabetes control. Diabetes and Exercise: A Note about Hypoglycemia
Although exercise is an excellent way to help control your blood glucose levels, it is not without its risks. One of the most serious risks of exercising when you have diabetes is a condition called hypoglycemia.
With hypoglycemia, increased activity causes your blood glucose to fall to dangerously low levels. This can happen while you are exercising or even many hours later. Hypoglycemia can make you feel shaky, weak, and confused. If your blood glucose levels drop low enough, hypoglycemia could cause you to faint or have a seizure.
Talk with your doctor about strategies for preventing hypoglycemia. You may need to have a snack before you exercise or closely monitor your blood glucose levels before, during, and after exercising.
In addition to eating healthfully and taking insulin or other diabetes medications, exercise is a valuable tool for keeping you healthy. Commit to a regular exercise program, and you will not only have better control over your diabetes, but you will also gain more self-confidence and a better sense of well-being.
By Krisha McCoy, MS
Medically reviewed by Pat F. Bass III, MD, MPH Print Email Exercise is important for everyone, but it can be especially important for your health if you have diabetes. People who exercise regularly are better able to control their diabetes, thereby reducing their risk of diabetes complications.
Diabetes and Exercise: Why It’s Important to Stay Fit
If you have diabetes, you have an increased risk of developing certain health conditions, including heart attack, stroke, kidney disease, and nerve problems. By following your doctor's recommendations for keeping your blood glucose levels under control, you can reduce your risk of developing these complications.
Researchers have found that people who exercise regularly have:
Lower blood glucose levels
Lower blood pressure
Better cholesterol levels
Improved ability to use insulin
Decreased risk of stroke
Decreased risk of heart diseaseStronger bones
Less chance of falling
Easier weight loss
Less body fat
More energy
Reduced stress levels
In addition, if you use insulin to treat your diabetes, exercise can be part of the daily schedule that you and your diabetes health care team develop to control your blood glucose levels.
Diabetes and Exercise: Getting Started
Talk with your diabetes health care team before you begin an exercise program. They can help you design an exercise program that is safe and effective for you. Make sure to ask about any limitations. If you have heart disease, kidney disease, eye problems, or foot problems, there may be some physical activities that you should not do.
To get started with an exercise program:
Find physical activities you like. Choose activities that you enjoy doing and that are convenient. Try new activities, such as walking, dancing, swimming, or bicycling, until you find one you like.Schedule your workouts. Make exercise part of your schedule, just like work and doctor appointments. Aim to work out for at least half an hour on most or all days of the week.Slowly increase your time and intensity. Don't start out doing too much, or you may get burned out. Begin with just a few minutes, and add a little time, distance, or intensity to your workouts each week.Find an exercise partner. Ask a friend or neighbor to join you in your exercise plan. For many people, having a person who is counting on you will make you less likely to skip a workout. Keep a workout journal. Each time you exercise, write down what you did and what your blood glucose levels were. That way you can keep track of your progress and see how activity affects your diabetes control. Diabetes and Exercise: A Note about Hypoglycemia
Although exercise is an excellent way to help control your blood glucose levels, it is not without its risks. One of the most serious risks of exercising when you have diabetes is a condition called hypoglycemia.
With hypoglycemia, increased activity causes your blood glucose to fall to dangerously low levels. This can happen while you are exercising or even many hours later. Hypoglycemia can make you feel shaky, weak, and confused. If your blood glucose levels drop low enough, hypoglycemia could cause you to faint or have a seizure.
Talk with your doctor about strategies for preventing hypoglycemia. You may need to have a snack before you exercise or closely monitor your blood glucose levels before, during, and after exercising.
In addition to eating healthfully and taking insulin or other diabetes medications, exercise is a valuable tool for keeping you healthy. Commit to a regular exercise program, and you will not only have better control over your diabetes, but you will also gain more self-confidence and a better sense of well-being.
Monday, January 31, 2011
Causes of Type 2 Diabetes
Causes of Type 2 Diabetes
Eating too much and exercising too little are two of the main reasons why people develop type 2 diabetes.
By Madeline Vann, MPH
Medically reviewed by Christine Wilmsen Craig, MD Print Email Insulin is a hormone made in the pancreas that allows glucose (sugar) to leave the bloodstream and enter the cells to be used as fuel. Type 2 diabetes occurs when the pancreas doesn't make enough insulin or the cells of the body become resistant to insulin. It is not known for certain why some people develop type 2 diabetes and some do not; however, there are several factors, such as genetics, obesity, and physical inactivity, that can increase a person's risk of developing type 2 diabetes.
Type 2 Diabetes: Primary Causes
Being obese or overweight puts you at significant risk for developing type 2 diabetes. Four out of five people with type 2 diabetes are overweight or obese.
“One of the links with obesity is that fat induces a mild, low-grade inflammation throughout the body that contributes to heart disease and diabetes,” says Vivian Fonseca, MD, professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans.
Excess fat, especially abdominal fat, also changes the way that your body responds to insulin, leading to a condition called insulin resistance. With this condition, your cells cannot use insulin to process blood sugar out of the blood, resulting in high blood sugar levels. While not everyone with insulin resistance develops diabetes, people with insulin resistance are at increased risk of type 2 diabetes.
Type 2 Diabetes: Poor Eating Habits
Eating too much of the wrong kinds of foods can increase your risk of type 2 diabetes. Studies have shown that eating a diet of calorie-dense, refined foods and beverages, such as sodas or fruit juices, and too little raw fruits, vegetables, and whole grains can significantly increase your risk of type 2 diabetes.
Type 2 Diabetes: Too Much TV Time
An analysis of health and nutrition data from a nationally representative sample of adults between the ages of 20 and 54 years of age showed that people who watched television more than two hours a day were more likely than their peers to be obese and to have diabetes. This is probably due to snacking while watching TV. The study found that the frequent TV watchers consumed, on average, 137 more calories a day than their peers. Conversely, the data indicated that cutting TV time back to less than 10 hours a week and adding a daily 30-minute walk led to 43 percent fewer cases of diabetes in the study group.
Type 2 Diabetes: Physical Inactivity
Just as body fat interacts with insulin and other hormones to affect diabetes development, so does muscle. Lean muscle mass, which can be increased through exercise and strength training, plays a role in protecting the body against insulin resistance and type 2 diabetes. A six-month study of 117 older men and women with abdominal obesity recently demonstrated that a mix of aerobic and resistance training exercises helped to reduce insulin resistance.
Type 2 Diabetes: Sleep Habits
Sleep disturbances have been shown to affect the body’s balance of insulin and blood sugar by increasing the demand on the pancreas. Over time, this can lead to type 2 diabetes. An analysis of data from 8,992 adults who participated in the First National Health and Nutrition Examination Survey showed that over the course of a decade, those who slept fewer than five hours a night or more than nine were at increased risk of type 2 diabetes.
Type 2 Diabetes: Genetics
Genes play an important role in determining a person's risk of type 2 diabetes. Researchers have identified at least 10 genetic variations linked to increased risk for this disease. However, your genes are not your fate; diet and exercise can prevent type 2 diabetes even if you have family members with the condition.
Eating too much and exercising too little are two of the main reasons why people develop type 2 diabetes.
By Madeline Vann, MPH
Medically reviewed by Christine Wilmsen Craig, MD Print Email Insulin is a hormone made in the pancreas that allows glucose (sugar) to leave the bloodstream and enter the cells to be used as fuel. Type 2 diabetes occurs when the pancreas doesn't make enough insulin or the cells of the body become resistant to insulin. It is not known for certain why some people develop type 2 diabetes and some do not; however, there are several factors, such as genetics, obesity, and physical inactivity, that can increase a person's risk of developing type 2 diabetes.
Type 2 Diabetes: Primary Causes
Being obese or overweight puts you at significant risk for developing type 2 diabetes. Four out of five people with type 2 diabetes are overweight or obese.
“One of the links with obesity is that fat induces a mild, low-grade inflammation throughout the body that contributes to heart disease and diabetes,” says Vivian Fonseca, MD, professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans.
Excess fat, especially abdominal fat, also changes the way that your body responds to insulin, leading to a condition called insulin resistance. With this condition, your cells cannot use insulin to process blood sugar out of the blood, resulting in high blood sugar levels. While not everyone with insulin resistance develops diabetes, people with insulin resistance are at increased risk of type 2 diabetes.
Type 2 Diabetes: Poor Eating Habits
Eating too much of the wrong kinds of foods can increase your risk of type 2 diabetes. Studies have shown that eating a diet of calorie-dense, refined foods and beverages, such as sodas or fruit juices, and too little raw fruits, vegetables, and whole grains can significantly increase your risk of type 2 diabetes.
Type 2 Diabetes: Too Much TV Time
An analysis of health and nutrition data from a nationally representative sample of adults between the ages of 20 and 54 years of age showed that people who watched television more than two hours a day were more likely than their peers to be obese and to have diabetes. This is probably due to snacking while watching TV. The study found that the frequent TV watchers consumed, on average, 137 more calories a day than their peers. Conversely, the data indicated that cutting TV time back to less than 10 hours a week and adding a daily 30-minute walk led to 43 percent fewer cases of diabetes in the study group.
Type 2 Diabetes: Physical Inactivity
Just as body fat interacts with insulin and other hormones to affect diabetes development, so does muscle. Lean muscle mass, which can be increased through exercise and strength training, plays a role in protecting the body against insulin resistance and type 2 diabetes. A six-month study of 117 older men and women with abdominal obesity recently demonstrated that a mix of aerobic and resistance training exercises helped to reduce insulin resistance.
Type 2 Diabetes: Sleep Habits
Sleep disturbances have been shown to affect the body’s balance of insulin and blood sugar by increasing the demand on the pancreas. Over time, this can lead to type 2 diabetes. An analysis of data from 8,992 adults who participated in the First National Health and Nutrition Examination Survey showed that over the course of a decade, those who slept fewer than five hours a night or more than nine were at increased risk of type 2 diabetes.
Type 2 Diabetes: Genetics
Genes play an important role in determining a person's risk of type 2 diabetes. Researchers have identified at least 10 genetic variations linked to increased risk for this disease. However, your genes are not your fate; diet and exercise can prevent type 2 diabetes even if you have family members with the condition.
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