Nutrition and Physical Activity
Speaker: Gary Scheiner MS, CDE
Expert Tips For Prescribing Physical Activity
Webinar Description: An exercise prescription is a way to incorporate the critical component of physical activity into the diabetes self-management plan for people with diabetes. Gary Scheiner, MS, CDE shares his expertise in this area. Gary describes the essential role physical activity plays in diabetes management, reviews strategies to minimize risks associated with physical activity in people with diabetes, and provides the tools necessary to design individualized physical activity plans for people with diabetes.
Expert Tips for Prescribing Exercise Q&A
with Gary Scheiner, MS, CDE
1. Question related to slide 33 (snacking to prevent hypo): Does this depend on their blood sugar before the workout--do you recommend that they check their blood sugar prior to exercise and have a snack if it is at a certain level?
Very good observation! The amounts on the chart assume that the blood glucose (BG) is within the patient's target range pre-workout. If higher, less carb is needed. If lower, more is needed.
2. What are the hormones that are part of causing hyperglycemia during activity?
Predominantly adrenal hormones (epinephrine/norepinephrine) along with cortisol.
3. Do you find most people whose blood glucose rises during exercise have type 1 vs. type 2 diabetes?
Depends on the "insulin dependency" of the person with diabetes. Those who can still produce a fair amount of their own insulin can produce enough to compensate for the adrenaline rush.
4. What would be the best option for activity for someone on multiple daily injections to avoid both hypo and hyperglycemia?
I don't think there is a single activity that works best for everyone. Intensive activities have the propensity to cause more dramatic BG changes, so moderate intensities are probably best for achieving stable BG.
5. What education is recommended for patients that might be trying to follow ketone type diet that want to exercise, risk for ketosis and safety?
Lots and lots of hydration is going to be essential. Performance may be hindered somewhat with very-low-carb diets, but it can still be done if adequate insulin is taken and hydration is maintained.
6. For a person that experiences hyperglycemia post-exercise in the morning hours before eating breakfast - what would you recommend to prevent those glucose spikes?
They may need to take insulin proactively prior to the workout. A conservative dose of rapid insulin is usually best.
7. How do you use continuous glucose monitoring (CGM) technology around exercise?
CGM is a great tool for seeing the direction BG is headed going into the workout, as well as to ward off lows during exercise and evaluating post-workout patterns.
8. What about someone with diabetes taking steroids for asthma and exercising and taking insulin? Due to different peak times with steroids and insulin, how do you incorporate exercise with these 2 conditions when steroids are prescribed long-term on daily basis?
I'd start out assuming that the inhaler has no effect… apply the usual insulin adjustments and see what happens. If BG rises, adjust the insulin accordingly.
Speaker: Paula Clinton, RD, CDE
Advanced Carbohydrate Counting
Webinar Description: Carbohydrates can have a significant impact on glucose; therefore, carbohydrate counting has become a cornerstone of diabetes education. Advanced carbohydrate counting is a method used to determine bolus insulin doses based on carbohydrate consumption, and also takes into account the impact of protein and fat on glucose.
Speaker: Hope Warshaw, MMSc, RD, CDE, BC-ADM
Helping People Make Healthy Lifestyle Changes – from Evidence to Practice
Webinar Description: Eating healthy and being healthy is a lifelong process, and weight loss and weight maintenance are crucial aspects of this process. People require different skill sets and behaviors for weight loss and weight maintenance. Losing weight is an important first step, which is then followed by more a permanent way of living so the weight stays off. Hope Warshaw, MMSc, RD, CDE, BC-ADM FAADE discusses principles of both weight loss and weight maintenance.
Answers to Questions:
Q: With so many people not being diagnosed with diabetes, why don't physicians add the A1c testing, so that we can prevent prediabetes from becoming T2D?
A: Good question! As we know an early diagnosis of type 2 diabetes as well as an early diagnosis of prediabetes is critically important to slowing the progression of the disease which really is a continuum. Prediabetes and type 2 diabetes, according to the American Diabetes Association’s diagnostic criteria (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html), can be diagnosed with either an A1c measure or blood glucose measures. While the awareness of prediabetes is rising, it is still very low. All healthcare providers need to do whatever we can to raise awareness and provide the important message that early action can help reverse or, more likely, slow the progression of prediabetes to type 2 diabetes. Let’s not just depend on busy primary care providers. In addition, it’s the provision of appropriate and adequate education and support, such as that provided by a variety of programs recognized by the National Diabetes Prevention Program recognition process (http://www.cdc.gov/diabetes/prevention/recognition/) and discussed in this webinar, that are and will make the impact. Unfortunately, screening or detection alone does not accomplish this.
Q: Was mindfulness compared or mentioned in the Obesity Guideline paper? What does the research say about this approach vs "lower calorie?"
A: To the best of my knowledge mindfulness as a “dietary approach” was not mentioned in this report (Jensen MD, et al. Guideline for the Management of Overweight and Obesity in Adults: A Report of the ACC, AHA, TOS Task Force on Practice Guidelines. Circulation. https://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437739....). However, the mindfulness approach and teaching concepts can be integrated into any dietary approach or be used alone to raise awareness and help a person change their relationship with food.
Q: High restraint and low disinhibition sound like contrary terms. How can both be factors?
A: I’ve gone back to the paper I referenced which recapped 10 years of follow up from the National Weight Control Registry (Graham Thomas J et al: Weight-loss maintenance for 10 yrs in NWCR. Am J Prev Med. 2014;46(1):17-23). I realize the terms seem contrary but perhaps these definitions will help. Dietary restraint is defined as a tendency to consciously restrict or control food intake so high restraint is the ability to restrain from intake when around food. Dietary disinhibition is defined as a tendency to overeat in the presence of palatable foods or other disinhibiting stimuli, such as emotional stress. Therefore low disinhibition is the ability to not overeat in these situations.
Q: Are there any apps that you like or recommend to your clients to track food intake?
A: There are many good apps available to help clients track their food intake such as myfitnesspal, fatsecret, livestrong, calorieking, and many others. However, what is most important is that the tracking tool a clinician suggests speaks to the individual and they can easily (and will) continue to use it. For some people just tracking intake with pencil and paper or in an excel document suffices. They don’t need or want a fancy, complicated app, while others want the latest tool.
Q: Can you suggest some menu planning websites (other than ADA) to assist patients in their weekly efforts to lower calories?
A: As with apps there are a multitude of menu planning and shopping websites and apps (some related). What’s most important is that clinicians offer a few of their picks to clients and then encourage them to try them out and see what they like best and feel they will use over time.
Q: How do you address inaccurate ideas that a client may cling too that are preventing them from being successful (e.g. I don’t over eat, I’m just sedentary).
A: I think its best that you try to dance with clients rather than doing battle. There’s usually plenty to focus on in the area of healthy lifestyle and behavior change. You may want to use the technique of asking if they are willing to try an experiment for a week or two to try something out that focuses on a concept they are clinging to. Therefore they will likely prove it incorrect. However, if a client is taking some actions that according to your knowledge are hazardous to their health, then you should let them know this or address it with their provider.
Q: Can you quantify "good glucose control?"
A: There are two sources of goals for glucose management for diabetes which includes both fasting and post-meal goals and A1c. First are the glycemic goals from the American Diabetes Association’s Clinical Practice Recommendations (http://care.diabetesjournals.org/content/39/Supplement_1/S13.full.pdf+html). The other set, which differ slightly, are the goals from American Association of Clinical Endocrinologists (AACE) at this link: https://www.aace.com/files/dm-guidelines-ccp.pdf. With either set of goals, it’s important to differentiate between diagnostic numbers and management goals.
Q: Is it ok to use a 2-3 carb per meal in females and 3-4 carb per meal for males for weight loss?
A: I don’t necessarily provide people with prediabetes or type 2 diabetes with a meal plan unless this is something that they ask for or I ascertain that it will be helpful. I’m much more inclined to help a person assess their current eating habits and food choices, particularly amounts of food they eat. With this information I would review their findings. I would encourage them to choose a few simple to achieve goals to tackle first, perhaps it’s what they are drinking (non-alcoholic and alcoholic beverages) or their portions or lack of fruits and vegetables. I recommend that you let a person’s food habits guide recommendations rather than overlaying a plan that might not work for them.
Q: I've seen research indicating limiting food intake to an 8-10 hour period per day boosts metabolism and decreases insulin resistance. Any comments?
A: I’m not familiar with this research. What we know decreases insulin resistance and increases insulin sensitivity is weight loss and sufficient physical activity. They’re both powerfully effective if implemented.
Q: What about timing of eating? PM? Nighttime?
A: As noted in the response to the last question, there are very few conclusions and consensus guidance on recommendations regarding the timing of eating or frequency of eating. I would emphasize that people you work with are likely to be more successful with weight loss and diabetes control with fewer behaviors they are asked to try to change. Let their current habits and food choices drive the process.
This study was mentioned by Kim Kelly, Pharm D, who was moderating our webinar: Jakubowicz D.: Fasting Until Noon Triggers Increased Postprandial Hyperglycemia and Impaired Insulin Response After Lunch and Dinner in Individuals With Type 2 Diabetes: A Randomized Clinical Trial. Diabetes Care. 2015;38:1820–1826.
Q: One of the recommendations for successful weight loss was not to count carbs. Often, patients must count carbs to determine their insulin doses. Any comments/suggestions on how to handle this?
A: This statement does not accurately reflect my statement during the webinar. The point I was making was about the research-based factors for long term successful weight loss and weight maintenance. Typically speaking these are individuals who are overweight and have been diagnosed with prediabetes or type 2 diabetes. The research shows that eating a relatively lower fat intake (<30%) is helpful. It’s important to note that the weight loss plan in both the Diabetes Prevention Program and in the Look AHEAD study focused on lower fat and total calories. They didn’t focus on a specific amount of carbohydrate or carbohydrate counting. I was not referring in my comments to people with type 2 diabetes who take meal-time bolus insulin and making dosing decisions based on the amount of carbohydrate they consume.
Webinar attendees provided the following responses to this discussion question: What are a couple of successful strategies you’ve used in your clinical practice to assist clients with their weight control efforts, either weight loss or long term control?
- Identifying eating triggers and reducing them is key
- Having the person develop 1-2 specific action plans/SMART goals, keeping food/activity journal, regular follow-up, team-based care
- Logging all they eat using an app
- I've seen the most success by tailoring the meal plan to the patients eating style with consideration to the amount of carbohydrate and glucose control
- Strategies - portion control, using a smaller plate, journaling