To see the full interview, click here.
Steve Freed — This is Steve Freed with Diabetes in Control and we’re here at the American Diabetes Association 77th scientific sessions 2017. We are here to present you some really exciting interviews with some of the top endos from all across the world. And with us we have a special guest who actually sits on our Board of Advisors, Sheri Colberg PhD, FACSM. Just give us a brief description of what you do.
Sheri Colberg — Well, I’ve been doing research and writing in the realm of physical activity and exercise for many years now. In fact, I’m sure you have prior videos of me talking about being physically active, so I am Professor Emerita of Exercise Science from Old Dominion University, so I’m doing everything I was doing before, just not teaching classes. So, I’m still doing consulting and lecturing and writing. I just completed another book for the American Diabetes Association that will be coming out in January on exercise and being active with diabetes.
Steve Freed – What’s the title?
Sheri Colberg — They have a publishing agreement with Wiley who does the “For Dummies” books. So it’s actually called Diabetes and Keeping Fit for Dummies.
Steve Freed – So let’ start off with what’s new in exercise physical activity and diabetes. I think everybody knows physical activity is good for diabetes.
Sheri Colberg — Well, part of the reason I’m at the meeting this year is to talk about a position statement that came out at the end of last year in November 2016, and when we did this position statement, we went back and reviewed what was the latest research that had been done pretty much since the last position statement, so in the last 5 or 6 years. And I think, you’re right. We all know exercise is good for us. We know what we should be doing for the most part. There are just for the few little changes and the main thing I think is a greater emphasis on not just doing structured exercise, although that is important, but also what we do in an unstructured way during the day. So, kind of unplanned. Certainly just moving around more all day, but even more importantly than that is probably just breaking up sitting time. There’s a whole bunch of research that’s come out in the last 5 years or so that’s looked specifically at what happens to your metabolism when you don’t sit for long periods of time and it’s all good to get up and move around probably every 30 minutes.
Steve Freed – So, what’s new about the new position statement from the ADA?
Sheri Colberg — Well, what makes it really unique is that it has been a long time since one hasn’t just focus on a particular type of diabetes. For example, ADA had one that was done jointly with the American College of Sports Medicine in 2010, but it was just focused on type 2 diabetes and pre-diabetes. So, this one actually includes type 1 diabetes, type 2 diabetes, gestational diabetes, so it kind of covers the whole gamut of anybody who could possibly have diabetes and what the recommendations would be for that. So, what we have also included in that is that pretty much everyone with diabetes should be doing four types of activities, if that isn’t enough to add into your daily life. Aerobic or cardio training for sure. That could just be simply walking. Resistance training, and there are many ways to do that, but that is really critically important. Flexibility training, which was in prior position statements, but there’s been a bigger emphasis now on balance training and how important that is, especially with an aging population. Because one of the biggest issues is that we have people who are falling and people with diabetes actually have a 17-time greater risk of having a fall and getting injured from that fall, and so really if you can prevent that by improving balance, you are doing a wealth of good in terms of preserving quality of life as well as longevity.
Steve Freed — So you talk about people getting better balance and you mention that it prevents people from falling. What do we need to do to improve our balance? Do we sit on a rubber ball or what?
Sheri Colberg – Well, actually there are a lot of ways to do it and that’s the beauty of it. The most simple thing you could do, that anyone could do, is just practice standing on one leg at a time. So you stand next to something where you can hold on and you may start with two hands or one hand until get to a point where it’s just one finger or no hands, and you practice standing on that leg for 30 seconds or a minute, and then you switch to the other leg and you do it several times a day and it’s amazing how much better your balance gets just practicing that. It’s not something we normally do. Just pretend you’re a flamingo and stand on one leg. And in addition to that, there are a number of resistance training exercises that we do for our core or lower body that also sort of double as balance training. So really in order to stay on our feet, we need to have a strong core and a strong lower body. Many of those exercises that you would be doing for the purpose of getting those areas stronger will also improve your balance. And then certainly you can use training tools. You can practice standing on uneven surface — a cushion, a Bosu balance training half ball — something where you actually have to use a variety of muscles to maintain that balance that you wouldn’t have to do normally if you’re just standing there on two feet.
Steve Freed — What are some of the type of exercise you can do?
Sheri Colberg — Interesting I might have a whole list of them that would provide you if you want, but basically it’s simple things like grabbing a towel with your toes, so you practice grabbing with your toes and see if you can grab onto a towel. Those are muscles that you don’t normally recruit and use, but in terms of standing, they are really important for stabilizing your foot. You can practice walking backwards along the wall. You can practice walking — this is also a test they make you do to see if you’re drunk — but you know, one foot in front of the other in a straight line. But also if I’m not as think as you drunk I am, I can straight a walk line. (Laughter) You can’t say that if you’re drunk, but it’s basically walking you know foot in front of a foot, which is not a normal walking pattern so there’s a lot more balance involved in staying on your feet. Just a lot of simple exercises like that.
Steve Freed — So what is the most important type of physical activity that everyone with diabetes should be doing? Or is there one?
Sheri Colberg — In my opinion, probably the most important, besides doing a little bit of balance training, which is easy to add in, is resistance training for the sheer fact that as we are aging we are losing muscle. And the muscle fibers that we lose specifically are the ones that were not recruiting and those are the ones that allow us to have more power. They are the ones you use when you sprint or you jump or you do something that requires an intense amount of activity for a short period of time. They’re not the ones that you just use walking. So, you need to have those additional fibers to stay strong to be able to do your daily activities, but you also need those because they’re a great place to store carbohydrate. So, the analogy I always uses is thinking of your muscle mass as a gas tank and what you want to have is a gas tank where you store carbohydrates. You want it to be as large as possible, which means retaining your muscle mass and you want it to be half full all the time. The only way to get it half full is by exercising and using up the carbohydrates that are stored in muscle. So, everyone should start doing some type of resistance training and that could be simple stuff that you do at home. There are many activities now that you can do that you simply use your own body weight as the resistance. You can do wall push-ups. You can do wall sits and all sorts of things that don’t require a lot of extra equipment or going into a gym to be able to do them. It’s really a trendy thing now to use your own body weight as your resistance.
Steve Freed – So, let’s talk about resistance exercise for a second. I could take two bottles of Bud Light and raise them over my head 20 times. That’s resistance, but that’s not going to give us a major benefit. I was always under the impression that when it comes to resistance you want to fail. You want to reach a point where you fail or you just can’t do it anymore and that will improve over time. What are your thoughts about that?
Sheri Colberg — Yes and not entirely. So, the research indicates that doing the heavier lifting that you’re talking about, completely to fatigue, is going to get you the most in terms of strength gains and certainly in retaining muscle mass, and that is true. But let’s say you’re the average person and you’re doing absolutely nothing right now. So, isn’t doing even your 12 oz Bud curls better than doing nothing at all? I mean at least you…and you can do it 100 times and eventually we will get fatigued doing that, but that works on more as muscular endurance and not so much muscular strength, but you get the idea though. You have to start with somewhere. So what a lot of people will start with is hand weights or they’ll use full water bottles or soup cans or something in their hands to add little bit of resistance. You can also get the stretch band that are resistance bands that come in different tensions so you can build up from low tension to a higher tension. And, again, using your own body weight, especially if you’re overweight, that’s going to be a lot of resistance. I mean I want to see how long you could do a plank. Can you do a plank for 5 minutes? I don’t think I could actually. And you build up, the more you do that, the stronger you get and that is the exercise that ends up being to fatigue. Although you know if you want to have the greatest gains, probably you want to use heavier weights or heavier resistance, but that’s not necessarily going to be the starting place for a lot of people.
Steve Freed — So, if you gotta exercise, aerobic certainly is good exercise. Anaerobic exercise and resistance training is good exercise. Do we know what percentage we should be doing of each? Everybody’s different obviously, but in general, do we have a percentage that we find that works best, specially for lowering blood sugars?
Sheri Colberg — Well, think of it this way. When it comes to aerobic or cardio training, you’re as good as your last workout. So if the effects of that are going to lower your blood glucose for maybe two to 72 hours max, you know, probably no more than 24 for most people, then you almost have to exercise daily or at least every other day with your cardio training. With your resistance training, the effect is more that you’re building muscle and in order to build muscle, the muscle needs time to repair after you break it down. So when you walk out of doing your resistance training, you’re weaker right then because you actually just destroyed muscle that now has to repair. When it builds back, it gets stronger and the recommendation for that is 2 to 3 non-consecutive days per week so that you have time to repair and recover in between the workouts. You can do a combination of those things, but the resistance training is going to have a longer lasting effects simply because you’ve built muscle and that muscles’ not going to go away in that to 2- to 72-hour period. It could couple weeks of de-training before you lose it. So you’re actually getting two different types of benefits from each of those types of training and they have shown that combining the two is actually better for glucose control, at least in people with type 2 diabetes so I would say aim do cardio at least 5 or 6 days a week or minimum at least every other day and add resistance training at least two days per week, but preferably 3, non-consecutive days
Steve Freed — How much time for each would you give for each if time was not an issue, as everybody says, “I don’t have time”?
Sheri Colberg — Well, it is interesting because now a lot of research has looked at what happen if you do your cardio training 5 minutes here, 5 minutes there. It all adds up and in the end, in terms of the glucose maintenance and weight control, it may be equally effective to do it in shorter bouts, so 10 minutes, we have time here. When you’re breaking up your sedentary time, you get up, you walk around for three minutes. You do that every hour or 30 minutes. That adds up to your 30 minutes during the course of the day and you didn’t actually break a sweat or have to go out on a planned walk. You’re just doing your little activities during the day and that actually works pretty well as far as handling blood glucose, preventing some of those post-meal spikes. I don’t think there’s a right or wrong way to do it. I think that the idea is to fit it in however you can do it. For the resistance training, maybe 15 to 30 minutes. It really depends on the exercises that you choose to do. If you try to do 8 to 10 different exercises, that may take you 20 minutes. if you do multiple sets, it could take you longer. Doing any of it it’s better than doing none of it. You can gain strength from just doing one set 1 time a week.
Steve Freed — Do we have any numbers as to the percentages of people with type 2 diabetes that basically really don’t follow the plan as far as exercise goes? I mean if you had to put a number from your experience, what percentage of people actually do what they need to do when it comes to type 2 diabetes?
Sheri Colberg — From the data I have seen, and it depends on the study, it’s generally less than the population as a whole and the population as a whole, fewer than half of all the adults meet the minimum requirements, so I would guess that it’s probably more in the range the last number I think I saw 38% maybe of those with type 2 but you know it’s not exact science and if you’re following it this month but not next month, where do you fall? That you’re just not doing anything or you just not doing it now? So, I think all of us can benefit from getting more physical activity, though. That’s without a doubt.
Steve Freed — Do we know why people with diabetes aren’t meeting the standards?
Sheri Colberg — I think there are number of barriers that exist for even the average person. You mentioned time constraints. So people have this, “I just don’t have time to exercise.” Well, that’s why I say put it here, put it there. When you break up your sedentary time and a couple studies actually had people doing light resistance training for 3 minutes every 30 minutes when they got up. They were just doing heel raises or toe raises where they were using their own body to lift themselves up. You could fit that in, I’m sure. As far as the other barriers, a lot of them have to do with health. As you know many people with type 2 diabetes in particular have a lot of comorbid health conditions that they are dealing with and so one of the things we did in the position statement, we went through all of these possible things — different cardiovascular disease, peripheral vascular disease, neuropathy that’s both peripheral or central, eye disease and so forth, and what are the recommendations if you have those. There are ways to work around practically every one of those so you can exercise safely doing at least something. And so it’s just a matter of finding out what would work for each individual person given the health status.
Steve Freed — My last question is, and I’m sure you do presentations all the time, if you’re presenting to PCPs and pharmacists and nurses and dietitians, what tips would you give them as far as talking to their patients. How do we motivate our patients to get more involved in physical activity. What would you want them to take away from your presentation?
Sheri Colberg – I think there are a couple things that they need to consider. One is what are the perceived barriers for the patient or the groups that they’re working because a big part of behavior change is getting past the excuses: I don’t have time. I don’t have anywhere to go and I don’t have anyone to watch my kids. You know if you can figure out what those barriers are and create some goals to overcome those, you’re halfway there. The other thing is in working with the limitations, if those are part of the barriers, and I think it’s also important to emphasize to people that exercise is more than just…it’s actually physical activity that we’re talking about, not just exercise. Physical activity is a broader term. Exercise is a type of physical activity that is very structured and planned and what not. You can be physically active all day long without fitting in structured exercise and if we start making people think about that, taking the stairs, walking around when you have some free time rather than sitting, all of that adds up and it’s just the little bits that add up over the day that are going to really have an impact for most people.
Steve Freed –– With all the new technology out there, have we found that maybe an automatic text that says, “It’s time now for you to get up and go for a 2-minute walk.” I’m sure there’s studies that show that can be beneficial because sometimes people get so actively involved in what they’re doing that they forget about it.
Sheri Colberg – Right. I think some of it is a culture change too. If you’re in a workplace and everybody looks at you strangely if you get up and stand during a meeting as opposed to sitting, then you’re going to sit back down. You’re going to go, “I don’t want to be the only one standing up.” Now, I don’t have a problem with it. I’ll be the only one standing up and then everybody starts standing up with me, but it has to be at a collective social change in the mindset of “Let’s not just be sedentary. Let’s have a standing meeting. Let’s have walking meetings. Let’s get together and do something active rather than something sedentary.” And once we all start thinking that way, I think it’ll be a lot easier to integrate because it’ll be a social norm as opposed to the odd duck who stands up during the meeting.
Steve Freed — Well I want to thank you for your time. It is exciting to get to see you at these meetings and learn something new. And enjoy the rest of your stay here.
Sheri Colberg – Thank you.