Science-backed Strategies to Help Clients Manage Diabetes
In the past 20 years, the number of adults diagnosed with type 2 diabetes has doubled. Currently, more than 27 million adults are managing what is often referred to as an incurable condition, although evidence has disputed this. Prediabetes, a reversible state of higher-than-normal blood sugars, is an increasing concern, impacting nearly 100 million adults in the United States. While prediabetes is reversible, more than 80% of individuals who have it are unaware they have the health condition.
As a health and exercise professional, you understand the impact of exercise and nutrition on both overall health and individual diseases, including diabetes. After all, clinical and health organizations such as the American Diabetes Association and the Centers for Disease Control and Prevention recommend lifestyle changes, including regular exercise, a healthy diet and reaching or maintaining a healthy weight, to prevent and manage diabetes.
In addition to the growing body of research demonstrating the impact of lifestyle on diabetes, recent advancements in glucose-monitoring devices now provide real-time access to personal glucose readings. These tools are accessible to both healthy and chronically ill populations.
And yet even with all this knowledge and all these readily available resources, the incidence of diabetes, both in the U.S. and around the world, continues to climb. Why is there such a widespread gap between knowledge and application? Could it be that, while generalized recommendations provide a basic framework for lifestyle change, they might actually be too broad? Are we urging clients to make wholesale lifestyle changes instead of helping them identify the individual habits and routines that, if changed, could profoundly impact their health?
A review of the science of habit formation is an opportunity to understand why some of these gaps exist. This research underscores the value of identifying and targeting simple, actionable strategies for change, and that targeting small daily or weekly habits is more likely to bring about lasting change.
When considering habits, it’s also important to identify barriers to change, such as a lack of time or inadequate financial resources. With regard to diabetes, generalized recommendations may also be considered a barrier, as most guidelines don’t account for personal factors such as fitness level, body composition or comorbidities such as heart disease.
Depending on their individual risk factors, some clients will benefit from even minimal interventions, particularly if they are currently leading a sedentary lifestyle. Clients who have fewer risk factors, such as those who already exercise regularly or do not struggle with overweight or obesity, may need to address multiple interventions, such as stress reduction or specific nutrition modifications. The point is to consider each client as an individual and to tailor guidelines to their unique needs.
The following recommendations offer practical application tactics related to physical activity and nutrition, while also providing guidance for the often-underutilized strategies for improved sleep and stress management.
Daily Physical Movement
Physical movement is a critical component of diabetes prevention and management. All physical activity lowers blood glucose levels. It also increases the body’s sensitivity to insulin, which is the hormone that allows cells in the body to use blood sugar for energy. While exercise has a specific role, a body in motion is one of the simplest and most essential ways to manage blood sugar.
Encourage your clients to start and end their day with movement. Initially, a client might create a one-minute movement goal by attaching it to a current habit. This might look like doing some yoga flow movements or plie squats while waiting for coffee to brew or while brushing their teeth, or doing some full-body stretches while in the shower. Just about any movement—arm circles, incline push-ups on the counter or burpees, to name just a few—will work. The bigger the motion, the better, but everything counts. Ideally, urge your clients to complete their activity within the first 30 minutes of waking.
For those who are ready to introduce more activity into their daily routines, establishing a habit of moving every hour can be highly beneficial. Clients who want greater control over their blood sugar might set a goal of standing up for three minutes or moving for one minute each hour. When standing is not an available option, urge your clients to perform simple movements such as engaging their posture, stretching the arms overhead, or flexing and pointing the toes.
Most smartphones and activity trackers offer the option to set movement reminders and notifications. Teach your clients how to use these beneficial features and, if they are comfortable doing so, urge them to share their data so you can monitor their progress toward their goals.
Ideally, adults should aim to perform at least 150 minutes of moderate-intensity exercise, plus at least two resistance-training sessions, per week. However, this can be a difficult target for many people to reach.
Historically, aerobic exercise has been the primary recommendation from healthcare providers, but there are limitations to this single-modality plan, and doesn’t address the needs of individuals who would benefit from increased muscle mass. While aerobic exercise uses glucose during activity, muscle mass both stores and uses glucose. While muscle tissue needs protein to grow, it is also the primary tissue where insulin stimulates glucose uptake to remove glucose from the blood and is a primary tissue for mediating whole-body glucose homeostasis. In addition, a reduction in muscle mass may be a risk factor for type 2 diabetes independent of insulin resistance, which reinforces the value of strength training and the importance of increasing muscle mass for these clients.
A deeper dive into the endocrine system reminds us that insulin resistance, a hallmark of both metabolic disease and diabetes, is an underlying mechanism for accelerating sarcopenia (loss of muscle mass). Clients with prediabetes or type 2 diabetes will lose muscle faster, especially those who have reached middle age and beyond. Understanding this physiological change highlights the importance of resistance training.
Of course, both aspects of exercise are essential and should be included in your recommendations. Even a single bout of exercise increases insulin sensitivity for up to 48 hours by improved glycemic control in individuals with type 2 diabetes. The specific modality should be based on your client’s fitness level and preferences.
For low-intensity exercise, 10 minutes of continuous exercise at an RPE of 2 to 5 (on a 0 to 10 scale) is recommended. A mix of walking, biking, light yoga and body-weight resistance-training activities is a good option for incorporating both muscular and aerobic training. Work with your clients to incorporate a variety of activities they enjoy or are willing to do and strive to find accessible options.
For clients who have a higher fitness level and, perhaps, more time constraints, a one- to three-minute stair climb after eating can be a good option for lowering blood sugar. This exercise should have a higher RPE of 5 to 7 and can be alternated with other higher-intensity functional movements, depending on the availability and fitness level of the individual.
Exercise timing is a crucial strategy for individuals with blood sugar challenges. While it may feel unusual to recommend post-meal exercise, scheduling exercise after meals is important to managing blood sugar. Fortunately, both low and high-intensity options are impactful and can be used interchangeably.
Although preferred, it is not necessary to do exercise immediately after a meal to see glucose-lowering benefits. Targeting a general 30-minute window to perform some form of exercise after eating is ideal, but this can be broadened if needed. The closer to mealtime the better, but something is better than nothing.
The most common strategies for managing blood sugar include reducing and avoiding sugar-sweetened, processed foods and beverages, as well as increasing fiber. However, there are additional nutritional strategies that you can offer your clients.
Reducing the frequency of meals to two to three daily can help reduce the impact of post-meal elevated blood sugar. Encourage clients to consume their last meal of the day three to four hours before sleep and to reduce their intake of simple carbohydrates and alcohol at the end of the day. These strategies can help them improve both blood glucose management and sleep quality.
Macronutrients other than carbohydrates have an impact on blood sugar. For example, for every 100 grams of protein consumed, the body produces around 60 grams of glucose. Early recommendations suggested that a high-protein diet decreases the risk of diabetes, but more recently, this statement has been clarified by protein type. Over the long term, a diet that contains high amounts of animal protein may actually increase the risk of developing type 2 diabetes, while a diet with plenty of plant-based proteins may modestly decrease this risk. However, it is important to keep in mind that research in this area continues to be mixed.
Sleep and Stress
While not often included in diabetes-management recommendations, sleep and stress are essential areas to address, as both play significant roles in how the body responds to insulin.
Sleep quality and quantity are both contributors to, and consequences of, insulin disturbance. In the short term, a single night of four hours of sleep disruption reduces insulin resistance in healthy adults. For individuals who have chronic sleep challenges, this insulin resistance may contribute to diabetes and obesity.
It can be a vicious cycle, as insulin resistance also contributes to sleep disruptions. Individuals with prediabetes have worse sleep quality than those with average glucose levels, which can accelerate the risk of developing type 2 diabetes.
Stress is also a factor in blood sugar management. Short-term acute stress, such as an exercise session, is healthy, and the body is well adapted to the stress response by happily burning up glucose storage in the muscles. With chronic, nonphysical stressors, however, blood glucose remains high for weeks or months at a time. These ongoing stressors trigger insulin release, as the body tries to manage this increased blood glucose level. Over time, the body has no choice but to adapt, leading to insulin resistance.
Addressing sleep quality should include sleep hygiene tips as well as routine. While sleep strategies tend to be focused on bedtime routines and sleeping conditions, looking at the wake cycle is also helpful. Work with your clients to create a consistent schedule of waking and rising out of bed. Exposure to morning light and one minute of movement upon arising should be encouraged.
Stress management should also be taken on as an active process. Urge your clients to adopt a regular meditation practice or spend time outdoors when possible. For some clients, stillness may be difficult, but taking a walk or listening to music are opportunities that are more accessible to create some stillness. Additionally, strong social connections are essential to reducing stress.
While each of these strategies is effective for helping to prevent or manage diabetes, they also have a positive impact on a wide range of chronic diseases. Take the time to educate all your clients about the important roles of diet, physical activity, sleep and stress, and how each of these are essential to reaching their broader health and fitness goals while improving both the quality and quantity of their lives.