Before I was a medical doctor, I was a fitness professional. After I left medicine, I became a fitness professional, a fitness professional who now knew the why’s and the how’s of fitness. I decided that my passion for fitness and my understanding of how the body works is more useful outside of an ICU rather than in it. I have dedicated my life to keeping people stay well, and catching a disease before end stage effects have occurred is critical. This is something that people with the disease often fail to realize.
Before I start on this proactive program, I do have to make some disclaimers. Even though I am a medical doctor, and I’m going to be explaining a medical diagnosis, it is imperative that anyone with a known medical or musculoskeletal disorder obtain consent from their doctor before starting any exercise program, even if their blood sugar tests and Hemoglobin A1C are within normal limits. With Diabetes, meds may need to be adjusted, there may be other disease processes going on, and there is a very distinct possibility that this person has not moved enough to know that they also suffer from coronary artery disease. The client should check their blood sugar before a workout, and it should be between 100 and 250 mg/dL. If blood sugar is above 250 mg/dL it is a proceed with caution situation. The client should test their urine for ketones if possible. If ketones are present, the workout should be postponed, because this is an indication that there may not be enough insulin available, and ketones are being formed. This would be a referral to the doctor situation. Also, with diabetes, the person you are working with is who does the blood sugar testing. It is beyond the scope of a fitness profession to stick a person to measure blood sugar. I am going to be giving you information to give you a better understanding of this disease, but if you see any of the things I’m going to talk about, it is so you will know when to refer back to their physician. Even I will not give medical advice when working in a fitness environment. Never start a workout with a blood sugar below 100mg/dL. Provide a rapidly absorbed carbohydrate source, and have them retest. Don’t let them convince you that it’s fine. It’s not, and it can have dangerous effects. Preventing harm is our number one rule, and remaining within the scope of our practice is number two.
Even though this is not the main topic of this article, I’d like to say a few things about Type I Diabetes, or Insulin Sensitive Diabetes. This is an autoimmune disease which typically begins before the age of ten. Antibodies are formed against the beta islet cells in the pancreas which are then destroyed, and the person has lost the ability to produce insulin. They will require insulin replacement for the rest of their lives. This is why it is called Insulin Sensitive Diabetes. They don’t have the ability to produce insulin, but if it is provided, their body will use it effectively. This form of Diabetes is most unfortunate, because adolescents are not that great at managing their disease, blood sugars, or even being able to appreciate the impact on their future life. Ends stage effects of the disease can begin to occur in their 20’s. This person’s insulin is tightly controlled based on their daily activity and calorie load. When they start an exercise program, their insulin will have to be adjusted based on the intensity and length of the activity as well as any increase/decrease of caloric intake. A Type I Diabetic must exercise at the same intensity every day of the week, because their insulin dose will have been adjusted to accommodate it. It doesn’t have to be the exact form or exercise type, but it has to be daily at the same intensity and duration. Because of this, and to decrease the risk of overtraining, the intensity will be lower with more of an emphasis on endurance. A 15-20 rep range of 40-50% of their one rep max, with 1 to 2 sets will be sufficient to start. Remember, if the intensity of their workouts is going to be increased, they must see their physician for insulin adjustments.
In addition, there are some people who are born with just a bad set of cards. No matter how much they try with exercise and diet to improve their disease state, they are unsuccessful. As fitness professionals, we must understand this and their disease, and be able to encourage and maintain adherence for someone who may be very frustrated. This can be accomplished by recognizing the lack of progression of their disease and the stability of their blood sugars. You may not be able to make it improve, but you can still provide a truly impactful improvement in their daily life. Most importantly, you may help them from reaching the end stage effects of uncontrolled diabetes: blindness, kidney failure, and limb amputations. Once these end stage effects are present, there is no going back. This is why it is so imperative that we are educated and prepared to handle this disease. We can make the biggest difference for the future of their lives.
Sugar floating in the blood, not being used like it should be, is like salt on your car in the winter. It corrodes blood vessels, and the ones that are destroyed first are the smallest capillaries, such as in the eye retina, kidney nephrons, and lower extremities. If the capillaries are damaged, appropriate oxygen transfer cannot occur across capillary membranes, and the surrounding tissue will be poorly perfused or die. With the amputations, there are a few bacteria that can cause very serious infections. There is a bacteria that loves a low oxygen/high sugar environment. It is Clostridium perfringes, and it is the bacteria that causes Gas Gangrene. There is no stopping it without a hyperbaric chamber, because there is not adequate perfusion with oxygenated blood or the perfusion to get antibiotics to the site of the infection. The treatment is often amputation. People can have this illness for years or decades before end stage effects occur, so there is time to make a difference. Education and preventative measures must be in place. The lock and key analogy I am going to describe is one of the most powerful ways I have conveyed this to people with Diabetes. It’s in terms that make sense to anyone. This is an instance when losing body fat plays second while we are saving a person’s life. The loss of body fat will follow.
What I am about to describe has enabled hundreds of people to decrease or eliminate their medications. You will be working as a team with this person’s doctor, and you will need to be vigilant monitoring signs of hypoglycemia, but I have seen this approach work in so many individuals. And, if this person is able to decrease or stop Metformin, Insulin, or other medications, exercise is not something they can do until they are off meds and then stop. They have already shown a predisposition for Type 2 Diabetes, and it will return if lifestyle choices are not maintained. The following explanation for how Type 2 Diabetes occurs has enabled me to educate thousands of personal trainers, clients, managers, and other support staff. I hope this analogy will help.
This first part is going to be the science behind this disorder. Bear with me as I explain it, because it will make the second half of this article so much easier to understand.
The pancreas is responsible for secreting insulin. When a carbohydrate is consumed, and it is broken down and absorbed into the bloodstream as sugar (glucose), the pancreas will secrete insulin. Insulin does not have a brain, it has a job. If Insulin is secreted, it will bind to a glucose molecule and take it to where it is needed. There are three organ systems in the body that must have sugar to survive. They are the brain, liver, and muscles, with muscles being the biggest user of these resources. There is an alternative inefficient way for the body to make sugar from protein and fats, but it is very ineffective at creating the appropriate amount of glucose needed, and it leads to the formation of ketones in the blood stream. This is why people on very low carb diets can be in a brain fog, have excessive ketone body formation from the liver (which causes the funny smell), and have massive amounts of muscle loss. Muscles are the biggest determinants of metabolism. We have to save them. Low carb diets are diets that a person cannot maintain long term, because they are just too deficient in nutrients. As this person on a low carbohydrate diet is losing weight, sadly, most of that weight is muscle weight, which means…when they can no longer stand the diet, they will be starting at a point with much less muscle mass and a lower metabolic rate. If they go back to their previous eating habits, this leads to adding weight much quicker.
Muscles and insulin have a very convenient working relationship. Carbohydrates are ingested, insulin is secreted, and insulin binds to glucose and takes it to where it is needed (muscles in this case), attaches to the Insulin receptor on the surface of a muscle cell and dumps the glucose into the muscle cell which is then renamed as glycogen. (There are a few additional steps in this process, but knowing that insulin is the key that opens a muscle cell is a great start.) Glucose and glycogen are the same thing. Glucose is in the blood stream, and glycogen is the storage form in a muscle cell, but they are the same. Not only does Insulin open the door for glucose, but it allows much needed amino acids to be delivered to the muscle cell as well. The muscle cell has a lock, insulin is the key, and insulin will continue to unlock the door until the muscle cell say enough! Muscles will only store as much glycogen as they need based on current activity levels. This is when problems occur, and it is why this is referred to as Insulin Resistant Diabetes. There is plenty of Insulin available, as long as the pancreas islet cells haven’t burned out, but there is a receptor for Insulin on the muscle cell surface (the lock). When over bombarded with glucose combined with a lack of movement, muscles will change the lock. There are plenty of keys (insulin), they just don’t match the lock. The great thing about this is….muscles don’t hold a grudge. They will only store what they need, but if they need more, they’ll be your best friend in a heart beat. Everything in the human body occurs across a concentration gradient. You make muscles work, and there will be a supply and demand reversal. The muscle will also take on additional water stores to create the concentration gradient for necessary components of glycolysis and the creatine phosphate system to enter the cell faster. This why there can be an initial 1-3 pound gain when someone starts a resistance training program. The muscles are building water stores to ensure they have the nutrients they need. It is just water.
The way we increase glycogen storage in a muscle cell is through anaerobic training. The exercises that make a muscle burn with lactic acid, the byproduct of glycolysis. Besides the creatine phosphate system, glycolysis is the anaerobic system involved in physical activity. Anaerobic metabolism has to be a huge part of the program design. Only by creating a situation where lactic acid is produced can you increase glycogen storage in a muscle cell. The muscles will change the lock back if they have a need. Every time you create lactic acid and make it burn for a person, you are increasing the stimulus to store more glycogen/glucose/sugar in the muscle cell. This can be a powerful coaching mechanism for you when working with clients who really just don’t like exercise, especially when it burns.
The program for someone with Type 2 Diabetes should be focused predominantly on lactic acid production. At first, this may be endurance activities to gradually build them up metabolically, but increasing the overload to 75% of their one rep max is the target. Not only does lactic acid increase glycogen storage and amino acid transfer, but fat burns in a carbohydrate flame. In addition, every time a muscle starts to burn, and then is hit again multiple times with minimal rest, you also increase the production of growth hormone and testosterone, which also increase muscle mass. The locks will stay open. I have personally had over a hundred people taken off their Metformin after a 3-4 month period. Everyone is different, and you should not tell someone to alter their medications or that they will eventually be able to stop them, but it is possible that it will happen. The program design will be 8 to 12 reps with an intensity of 75-85% (once they have built up to it), 3 sets, with 45-90 rest intervals. HIIT is also an excellent alternative for Insulin Resistance. It utilizes all three energy systems, increasing muscle storage of all key ingredients for muscle metabolism. Caloric burn can increase exponentially.
My greatest success with this analogy of the lock and key is when I have been sitting with one person or small group in front of me explaining how this works. I draw out the digestive track with the pancreas right below the stomach, I show the army of insulin attached to glucose, and I draw stop signs on the muscle cell surface to represent the receptor change. That’s why it’s called Insulin Resistant Diabetes. There is plenty of insulin available, but the muscles simply says “No More”. Reversing that process, and saving someone’s sight, avoiding dialysis and kidney transplant, or keeping their appendages attached are well worth the conversation. This description can be the exact conversation that will get someone to push themselves to the point of discomforting muscle burn or fatigue from lactic acid pooling. Getting muscles to fight against type 2 diabetes is better than any pill. You’ve just made a permanent difference in their live at a critical fork in the road.
Hypoglycemia (a blood sugar that is too low) in this population group is always a concern. If you are working with someone who has Diabetes of either type, you must always have a fast acting glucose supply readily available. It can be fruit juice, glucose tablets, pure sugar, or my favorite, Mike-n-Ikes. I’ve never seen anything enter the blood stream faster. The symptoms of hypoglycemia start with shaking, dizziness, sweating, nervousness, irritability, and often a ravenous hunger. If no glucose supply is ingested, these symptoms can proceed to confusion, abnormal behavior (often violently aggressive), blurred vision, seizures, loss of consciousness, and then death. Having sugar available can be the difference between life and death for this person. Make sure you always have it on hand.
Please feel free to connect with me on LinkedIn if you have questions, or comment on my blog page. I’m happy to help, and I would enjoy hearing about your successes with this program.