In my (primary) field of Physical Medicine & Rehabilitation, I am exposed to the back end of complications related to difficult to control diabetes. I say “difficult to control,” because in many cases individuals can follow their medical team’s instructions closely and still struggle to bring their hemoglobin A1c% close to the target of under 6-6.5%. While sitting at a table at the Annual Diabetes Wellness Expo in Dover, DE, I thought this would be an excellent time to discuss how we address diabetes in our objectively unique way.

I’d like to caveat upfront that I am not an endocrinologist; I am not even board certified in internal medicine. However, I have helped countless individuals improve their blood sugar control, reduce/eliminate need for insulin injections, and add years back to their lives. On the other hand, I’ve also seen the strokes, heart attacks, chronic pain, kidney disease, and other complications that happen when diabetes progresses unchecked.

Why else is our team qualified to comment on this topic? Angela’s a Family Nurse Practitioner by training and has worked with countless patients across the age spectrum who have struggled with controlling blood sugar. Besides the experience I’ve already listed, my internship training was in Internal Medicine, and I am board eligible- certified, hopefully, pending exam results- in Obesity Medicine.

Regardless, nothing in this post should be taken as medical advice. We present this information for educational purposes so that you may continue your own research and bring questions and conversation points to your own medical team.

Metabolic Care

These are three domains where someone like me with a background in pain management and obesity medicine can influence diabetes the most. In contrast, an endocrinologist specializing in diabetes would likely have a completely different perspective and skillset in addressing these domains. In fact, they may even have an entirely different set of priorities and strategies.

I approach most disease processes as if we are building a prehabilitation program- on the clock, racing towards a major medical procedure. What dominoes can we knock over and leverage into bigger improvements in other areas? Diabetes, in particular, necessitates this perspective because the opposite is also true. If we don’t act enthusiastically, more time passes, allowing complications to develop. For example, how can we quickly address pain limitations to permit greater physical activity as soon as possible? With this in mind, here’s our general plan of attack.  

1. Exercise: In the case of health optimization, the direct purpose of exercise isn’t weight loss, despite what one may expect. Instead, exercise has many benefits for blood sugar control and metabolic health, well before any significant weight loss is achieved. As we touched on in an early post, our exercise goal for patients with diabetes is essentially to “free up” space in the body to more easily store glucose- blood sugar. By focusing on a combination of strength training with compound exercises and moderate intensity aerobic exercise, you can burn stored glucose while building muscle for more space to store it later.

The real expertise lies in designing a program that fits this description while also following the number one rule: the ideal exercise is whatever one you will actually do. For the strength training, it can be a combination of using barbells, dumbbells, machines, and bodyweight exercise. The “compound” aspect just means the exercise recruits multiple muscles to the point that multiple joints are moving- i.e., a squat requires movement through the hip, knee, and ankle joints. Alternatively, a leg extension only requires movement through the knee. Compound movements allow you to work more muscle in less time, maximizing the muscle building, anti-inflammatory, and calorie burning burning benefits. By doing moderate intensity aerobic exercise, you can also stimulate uptake of blood sugar by the muscles without needing insulin to do so; this is a perfect strategy in the setting of diabetes since insulin is in short supply or doesn’t work well enough alone (insulin resistance).

As far as the other major components of “metabolic care,” we want to control blood sugar in the short term, while reversing insulin resistance in the longer run. In other words, dietary strategies will often involve calorie and carbohydrate restriction to burn fat and reduce high blood sugar episodes, respectively. Medication selection will ideally support both weight loss and blood sugar control, like the new injectable medications or at least blood sugar control in a weight neutral mechanism, like with SGLT-2 inhibitors such as Jardiance and Farxiga, metformin, or DPP-4 inhibitors like Januvia and Tradjenta. If needed, insulin injections can quickly control blood sugar and relieve stress on an overworked pancreas, but for the long term, we want to minimize the need for insulin as it promotes weight gain and has other risks.

2. Pain Management: “pain” in the context of diabetes is very multifactorial. Besides the typical “diabetic peripheral neuropathy,” individuals with metabolic disease are more likely to experience different nerve-type pain like carpal tunnel syndrome, “plexopathies,” and sciatica-type pain from any number of pinched nerves. On top of these, arthritis, fibromyalgia, and muscle/tendon injuries all occur more frequently. Basically, most types of pain occur more frequently in individuals with obesity and/or diabetes due to both the inflammatory and mechanical (i.e. bodyweight) stress on joints, nerves, and muscles/tendons. In fact, diabetes amplifies the negative impact of one cause due to the other. In other words, carpal tunnel syndrome is a compressive neuropathy (the median nerve is literally compressed within the carpal tunnel).  Diabetes, then, increases the sensitivity of that nerve to mechanical compression.

3. Complication Management: I’m using this as a catch-all for most of the other high-profile, negative impacts of diabetes when it is not tightly controlled. A well-formed strategy, for example, will include treatment of sleep apnea early because it will reduce stress on diseased kidneys, blood sugar fluctuations, and blood pressure. It will also improve willingness to exercise and physical improvements to it.

Other important complications we address at the same time include joint diseases and heart disease to improve exercise tolerance and reduce risks for complications during exercise. When it comes to arthritis, however, injecting a steroid medication into the joint may treat the pain, but it can also worsen blood sugar control. Interestingly, certain non-steroidal anti-inflammatory medications like ketorolac (Toradol) are safe to be injected into joints and offer comparable pain improvement. By injecting it straight into the location of pain and inflammation, the NSAID will have less impact on kidney health than if it were taken by mouth.

Takeaways for Today

This only scratches the surface of what we’d consider a comprehensive diabetic plan. Inherently, every person’s plan will be unique, and given the number of organs in the body affected by diabetes (all of them), a treatment program requires many perspectives. The end goal is to get blood sugar to stay within a healthy range, but the approach requires an understanding of all barriers to exercise, weight loss, nutritional optimization, and anything else required for sustainable behavioral change.

A couple things you could do to get started:

1. “Survey the field”- look inward and determine what exercises you like to do, regardless of if you can actually do them at the moment. What exercises or physical activities do you want to learn? What are your fears of trying these- risking injury, looking silly, etc.?

What high protein foods do you enjoy? What high protein snacks, powder supplements, etc. do you know of that can help you make up your total daily protein requirements?

What are your biggest short and long term fears related to diabetes?

2. Identify barriers and motivations- what’s stopping you from exercising? Is it pain and, if so, what kind? Limited experience with fitness and nutrition? Fatigue? Depression?

List out the diabetes complication fears you have, and put this list in a visible place such as on your desk, near the front door, on the calendar, or in the pantry. Use this as fuel whenever you’re having a day where motivation is running low, or use this list to maintain willpower when trying to improve certain habits.

3. Seek out experts- bring your list of preferences and limitations to facilitators, such as personal trainers, physical therapists, nutritionists, or, gee I’m just thinking out loud here, a comprehensive medical practice that can address those limitations and build you a roadmap to success. Even if that practice isn’t Admire Medical, showing up to your medical appointment prepared and with questions in hand ensures you are an active participant in your health. It demonstrates to your medical team that you are in the driver’s seat here, and confirms that our role is to provide recommendations, not to dictate orders to you.

This is a topic we will likely revisit soon to add dive deeper into one of the themes- goal setting for success, a masterclass in pain management without needing opioids, high-protein food selection, or something related to headlines in the news at that time.

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Until then, be well!

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