A doctor explains why you don’t need a medical degree to improve the health and fitness of a client with diabetes … as long as you remember the limits of your expertise.
I live in two different worlds. Professionally, I’m a physician who’s board-certified in family and obesity medicine. But on my own time I’m an athlete and a meathead with sub-10 percent body fat. I love to lift heavy things, and don’t think there’s anything weird about flexing in the mirror afterward. Sometimes I don’t even wait until I’m finished.
So when I approach my patients who have type 2 diabetes, the part of me that’s a gym bro wants to get them into the weight room four days a week while setting them up with a protein-sparing low-calorie diet. But the part of me that’s a doctor understands there’s almost no chance it would work.
That’s because type 2 diabetes, like me, is really two things: Medically, it’s a disruption in the way the body processes blood sugar. But behaviorally, in most cases, it’s a disease of excess—too much food, and too little exercise, for too long, with plenty of warning signs along the way.
I wish every client with diabetes came to you on the advice of a doctor like me, someone who understands how to combine the fitness and nutrition interventions you provide with the client’s prescribed medicines, with all of you working toward a mutual goal of helping the client lose weight, get healthy, and no longer need that medicine.
But with or without that kind of collaboration, there’s a lot you can do. Exercise, I believe, is the very best therapy, one that’s safe and powerful and 100 percent legal for you to prescribe. You can also recommend the second-best therapy: diet modifications that lead to weight loss.
The combination, when applied intelligently, can have profound effects on your client’s physical and mental health. Here’s the program I recommend.
Part 1: Exercise
If I could, I’d get every patient with type 2 diabetes on a program that combines strength training and endurance exercise. The balance would be up to the patient. A little cardio with a lot of lifting or a ton of cardio with a bit of lifting will get her to the same place. She’ll have better insulin sensitivity because when she uses glucose and fat as fuel there’s less of it in her bloodstream.
But if a typical patient could do a program like that, she probably wouldn’t have diabetes in the first place.
So my challenge, and yours, is to meet these clients where they are now—which, in many cases, is at the very beginning.
Step 1: Start Lifting
To my patients, the gym is an intimidating place. You’d think someone like me wouldn’t be able to relate, but I totally can. A few years ago, when I decided to do a triathlon, I had to start swimming laps, something I’d never done in my life. (My ever-supportive wife said it looked more like drowning than swimming.)
Yes, I looked good in my Speedo, but I was by far the worst swimmer in the pool. And you’d better believe it bothered me. I’ve never finished last in anything.
Now imagine how your client feels about herself when she walks into a room filled with people who are leaner and fitter, and who obviously know what they’re doing. The last thing you want to do is give that client exercises that make her feel even more awkward than she already does.
I hope this is common sense, and that you wouldn’t start a client like this with single-leg Romanian deadlifts, or anything on a Swiss ball. But I’ve heard stories …
The ideal program is the simplest one that you think will get results, with one to three sets of each of the following movement patterns:
- Hip hinge
- Vertical and/or horizontal push
- Vertical and/or horizontal pull
- Biceps curl (not necessary, but no one is afraid to try it)
- Triceps extension (also not necessary, but female clients especially will expect it)
- Core-stability exercises
Keep in mind that you can’t reverse decades of sedentary behavior overnight. The best you can do is start the ball rolling in the opposite direction.
Step 2: Get Moving
This is where I start with my patients: a short walk after dinner. We know that a 20-minute walk can lower the blood-sugar response to a meal. A 30-minute walk would be better, but it’s okay if your client builds up to it.
I hope your client’s doctor already has him doing this. But if not, you need to encourage it.
Walking checks multiple boxes:
- It’s easy, simple, and gives clients a stronger sense of self-efficacy.
- It’s easily scalable; once a client is moving, you can encourage him to go a little farther, or a little faster, or a little more often.
- It’s a great rut-buster, getting your client away from his phone or TV or computer.
Once your client is experiencing some success, both in and out of the gym, it’s much easier to get him to modify his diet.
Part 2: Nutrition and Weight Loss
The biggest problem I see with nutrition advice is that most people are too extreme. On one side you have fitness pros who pretend they’re doctors, giving recommendations that could be disastrous without close medical supervision. On the other I see trainers who feel they’re so far out of their depth that they can’t give any advice, which is almost equally ludicrous.
I’ll start with the most popular extreme: low-carb diets.
There’s no question that cutting carbs reduces high blood sugar. The first suggestion I give to patients is to replace high-starch carbs like potatoes and bread with non-starchy vegetables. It’s simple and easy.
What’s not simple or easy is asking a patient to give up everything she enjoys and switch to a diet that fitness pros may think is awesome but most people hate. I don’t use that word lightly. Most of my patients despise the ketogenic diet, which is why I only recommend it if the patient has been on high insulin doses for at least 10 years.
My patients, and your clients, aren’t robots that we can program to follow the diet we think would be best for them.
The most effective diet ever studied, in fact, isn’t even low in carbs—at least not as a percentage of calories. It’s the very-low-calorie diet used by Dr. Roy Taylor at Newcastle University in the U.K. Volunteers with type 2 diabetes eat just 800 calories a day for several months, with the goal of losing at least 30 pounds.
The success rate is extraordinary, in large part because it addresses the underlying issue: the accumulation of ectopic fat in the pancreas (which makes insulin), liver, and muscle tissue.
It works as well as advertised, in my experience, but it’s way beyond anything a trainer should recommend.
Your best bet is to help your client achieve an energy deficit. It absolutely doesn’t matter how you achieve it. Weight loss almost always reduces blood glucose and improves insulin sensitivity.
Here’s how I would get started.
READ ALSO: Five Ways to Help Your Clients Lose Weight
Step 1: Impose Order
Help your client reduce the chaos in his diet by encouraging him to do the following:
- Eat a regular number of meals.
- Eat at regular times.
- Build a small list of what I call “go to” meals, which he can make easily and quickly, often with ingredients he has on hand.
- Make the meal his only focus for the time he sits down to eat it.
Step 2: Reduce Portion Sizes
Encourage your client to use smaller plates, smaller glasses, even smaller cutlery if he has it.
These are obviously symbolic steps, since he knows the goal is to create the illusion of eating the same amount when he’s in fact eating less.
But it might work anyway, simply because it’s his choice. It’s empowering because nobody is forcing it on him.
Celebrate Small Victories
Let’s return to something I said earlier: Type 2 diabetes is a disease of excess, with damage accumulating over years. Your client may feel like it came on suddenly—one day she’s healthy, the next her blood glucose levels are setting off alarm bells—but it took a long time for her to reach that tipping point.
Because every step matters on the road to diabetes, every step back toward normalcy is important.
Your client got stronger? That’s a win. Increased muscular endurance, or the total volume of a workout? Win. Walked every evening after dinner, and two hours on the weekend? Huge win.
Same with incremental decreases in weight and waist size. For that matter, if the client has steadily gained weight for a decade or more, simply not gaining weight for six months to a year can be a win, especially if she’s also increased her exercise and improved the quality of her diet.
Another reason why these seemingly modest achievements matter:
If your client is taking insulin or a class of drugs calls sulfonylureas (SFUs), you actually don’t want her to increase exercise too much or drop weight too quickly, unless you’re working closely with her doctor. She can end up with hypoglycemia—too little blood glucose. More gradual improvements give her doctor a chance to monitor her progress and reduce medications accordingly.
On the other hand, if you are working with her doctor, you can be as aggressive as your client wants. Some of them will surprise you.
But until you have that buy-in, remember that any progress is better than no progress.