December 19, 2013 · 4:32 PM

High Blood Sugar Raises Risk for Dementia, Even For Non-Diabetics

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

“Let’s work on getting those blood sugars down, honey.”

On the heels of a report finding no association between Alzheimer’s disease and abnormal blood sugar metabolism, MedPageToday features an new study linking high blood sugars to future development of dementia. And diabetics with sugar levels higher than other diabetics were more prone to develop dementia.

Some of you have already noted that not all cases of dementia are Alzheimer’s dementia. But Alzheimer’s accounts for a solid majority of dementia cases, about eight in 10 cases.

Some quotes from MedPageToday:

During a median follow-up of 6.8 years, 524 participants [of the 2,000 total] developed dementia, consisting of 74 with diabetes and 450 without. Patients without diabetes and who developed dementia had significantly higher average glucose levels in the 5 years before diagnosis of dementia (P=0.01). The difference translated into a hazard ratio of 1.18 (95% CI 1.04-1.33).

…

Among the patients with diabetes, glucose levels averaged 190 mg/dL in those who developed dementia versus 160 mg/dL in those who did not. The difference represented a 40% increase in the hazard for dementia (HR 1.40, 95% CI 1.12-1.76).

—Steve Parker, M.D.

Reference: Crane PK et al. “Glucose Levels and Risk of Dementia” N Engl J Med 2013; 369: 540-548.

Reminder: Conquer Diabetes and Prediabetes is now available on Kindle.

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December 16, 2013 · 12:15 PM

Can You Manage Your Type 2 Diabetes Without Drugs?

David Mendosa says you can. I’m not quite that optimistic, but probably a majority can, if they have the knowledge, discipline, and willpower. Here are some snippets from David’s blog:

You can use drugs to bring your A1C level down to normal. That’s a good thing. But this strategy does have its costs, and those costs aren’t just money out of your pocket or your checkbook. The worst of those costs are the potential side effects of the drugs.

***

But some of us think we have a safer strategy of managing our diabetes without drugs. Back in 2007 I joined this group with the encouragement of a good friend of mine who is a Certified Diabetes Educator. Before that, I had 14 years of experience taking a wide range of diabetes drugs, including two different sulfonylureas (Diaßeta and Amyrl), Glucophage (metformin), and Byetta. For the past six years I haven’t taking any diabetes drugs, and yet I keep my diabetes in control with an A1C level usually about 5.4.

I had to make three big changes in my life when I went off the diabetes drugs, and they are hard at first. But now they are a routine part of my life, and I would never go back to my old ways. The changes that I had to make are those that almost everyone who has diabetes has to make. In order of importance, I had (1) to lose weight, (2) eat fewer carbohydrates, and (3) exercise more.

Read the whole enchilada. It’s brief.

Steve Parker, M.D.

 

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December 10, 2013 · 4:03 AM

What Causes Type 2 Diabetes?

diabetic diet, low-carb Mediterranean Diet, low-carb, Conquer Diabetes and Prediabetes

Stop reading this sciencey post when you get bored

According to Roy Taylor, “type 2 diabetes is a potentially reversible metabolic state precipitated by the single cause of chronic excess intraorgan fat.” The organs accumulating fat are the liver and pancreas. He is certain “…that the disease process can be halted with restoration of normal carbohydrate and fat metabolism.” I read Taylor’s article published earlier this year in Diabetes Care.

[Do you remember that report in 2011 touting cure of T2 diabetes with a very low calorie diet? Taylor was the leader. The study involved only 11 patients, eating 600 calories a day for eight weeks.]

Dr. Taylor (M.D.) says that severe calorie restriction is similar to the effect of bariatric surgery in curing or controlling diabetes. Within a week of either intervention, liver fat content is greatly reduced, liver insulin sensitivity returns, and fasting blood sugar levels can return to normal. During the first eight weeks after intervention, pancreatic fat content falls, with associated steadily increasing rates of insulin secretion by the pancreas beta cells.

bariatric surgery, Steve Parker MD

Band Gastric Bypass Surgery (not the only type of gastric bypass): very successful at “curing” T2 diabetes if you survive the operation

Taylor’s ideas, by the way, dovetail with Roger Unger’s 2008 lipocentric theory of diabetes. Click for more ideas on the cause of T2 diabetes.

Here are some scattered points from Taylors article. He backs up most of them with references:

  • In T2 diabetes, improvement in fasting blood sugar reflects improved liver insulin sensitivity more than muscle insulin sensitivity.
  • The more fat accumulation in the liver, the less it is sensitive to insulin. If a T2 is treated with insulin, the insulin dose is positively linked to how much fat is in the liver.
  • In a T2 who starts insulin injections, liver fat stores tend to decrease. That’s because of suppression of the body’s own insulin delivery from the pancreas to the liver via the portal vein.
  • Whether obese or not, those with higher circulating insulin levels “…have markedly increased rates of hepatic de novo lipogenesis.” That means their livers are making fat. That fat (triglycerides or triacylglycerol) will be either burned in the liver for energy (oxidized), pushed into the blood stream for use elsewhere, or stored in the liver. Fatty acids are components of triglycerides. Excessive fatty acid intermediaries in liver cells—diglycerides and ceramide—are thought to interfere with insulin’s action, i.e., contribute to insulin resistance in the liver.
  • “Fasting plasma glucose concentration depends entirely on the fasting rate of hepatic [liver] glucose production and, hence, on its sensitivity to suppression by insulin.”
  • Physical activity, low-calorie diets, and thiazolidinediones reduce the pancreas’ insulin output and reduce liver fat levels.
  • Most T2 diabetics have above-average liver fat content. MRI scans are more accurate than ultrasound for finding it.
  • T2 diabetics have on average only half of the pancreas beta cell mass of non-diabetics. As the years pass, more beta cells are lost. Is the a way to preserve these insulin-producing cells, or to increase their numbers? “…it is conceivable that removal of adverse factors could result in restoration of normal beta cell number, even late in the disease.”
  • “Chronic exposure of [pancreatic] beta cells to triacylglycerol [triglycerides] or fatty acids…decreases beta cell capacity to respond to an acute increase in glucose levels.” In test tubes, fatty acids inhibit formation of new beta cells, an effect enhanced by increased glucose concentration.
  • There’s a fair amount of overlap in pancreas fat content comparing T2 diabetics and non-diabetics. It may be that people with T2 diabetes are somehow more susceptible to adverse effects of the fat via genetic and epigenetic factors.
  • “If a person has type 2 diabetes, there is more fat in the liver and pancreas than he or she an cope with.”
  • Here’s Dr. Taylor’s Twin Cycle Hypothesis of Etiology of Type 2 Diabetes: “The accumulation of fat in liver and secondarily in the pancreas will lead to self-reinforcing cycles that interact to bring about type 2 diabetes. Fatty liver leads to impaired fasting glucose metabolism and increases export of VLDL triacylglcerol [triglycerides], which increases fat delivery to all tissues, including the [pancreas] islets. The liver and pancreas cycles drive onward after diagnosis with steadily decreasing beta cell function. However, of note, observations of the reversal of type 2 diabetes confirm that if the primary influence of positive calorie balance is removed, the the processes are reversible.”
diabetic diet, etiology of type 2 diabetes, Roy Taylor, type 2 diabetes reversal

Figure 6 from the article: Dr. Taylor’s Twin Cycle Hypothesis of Etiology of Type 2 Diabetes

  • The caption with Figure 6 states: “During long-term intake of more calories than are expended each day, any excess carbohydrate must undergo de novo lipogenesis [creation of fat], which particularly promotes fat accumulation in the liver.”
  • “The extent of weight gloss required to reverse type 2 diabetes is much greater than conventionally advised.” We’re looking at around 15 kg (33 lb) or 20% of body weight, assuming the patient is obese to start.  “The initial major loss of body weight demands a substantial reduction in energy intake. After weight loss, steady weight is most effectively achieved by a combination of dietary restriction and physical activity.”

Dr. Taylor doesn’t specify how much calorie restriction he recommends, but reading between the lines, I think he likes his 600 cals/day for eight weeks program. That will have a have a high drop-out rate. I suspect a variety of existing ketogenic diets may be just as successful and more realistic, even if it takes more than eight weeks. I wonder how many of the 11 “cures” from the 2011 study have persisted.

Steve Parker, M.D.

Reference: Taylor, Roy. Type 2 diabetes: Etiology and reversibility. Diabetes Care, April 2013, vol. 36, no. 4, pp:1047-1055.

Update December 16, 2013:

Some wild and crazy guys tried this method at home. Click for results.

h/t commenter PhilT.

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December 9, 2013 · 4:24 PM

What’s the Best Diet for Type 2 Diabetics?

DietDoctor has some ideas based on a recent scientific study:

A new exciting Swedish study provides us with strong clues on how a person with diabetes should eat (and how to eat to maximize fat burning). It’s the first study to examine in detail how various blood markers change throughout the day depending on what a diabetic person eats.

The study examined the effects of three different diets in 19 subjects with diabetes type 2. They consumed breakfast and lunch under supervision in a diabetes ward. The caloric intake in the three diets examined was the same, but the diets differed in the following manner:

  1. A conventional low-fat diet (45-56% carbs)
  2. A Mediterranean diet with coffee only for breakfast (= similar to 16:8 intermittent fasting) and a big lunch (32-35% carbs)
  3. A moderate low-carbohydrate diet (16-24% carbs)

All participants tested all three diets, one diet each day in randomized order.

Click through for results. Hint: Carbohydrate restriction works.

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December 7, 2013 · 6:41 AM

Sugary Drinks Linked to Overweight in Preschoolers

…according to an article at MedPageToday. A sample:

DeBoer and colleagues evaluated the effect of sugary drinks on body mass index in 9,600 children evaluated at ages 9 months, 2 years, 4 years, and 5 years, who were enrolled in the Early Childhood Longitudinal Survey — Birth Cohort, a representative survey of the U.S. population of children born in 2001.

Parents answered survey questions about beverage intake at ages 2, 4, and 5. Sugar-sweetened beverages were defined as soda, sports drinks, and fruit drinks that were not 100% fruit juice. They also looked at when the drinks were consumed — such as at meals or with snacks — and if the child was a regular or infrequent/nondrinker.

diabetic diet, low-carb mediterranean diet

Why not teach your kids to cook?

Toddlers drinking at least one sugary drink daily were much more likely to have mothers who were overweight or obese. The sugared-up kids also watched more TV and drank less milk.

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December 3, 2013 · 2:00 AM

Meal Plans To “Conquer Diabetes and Prediabetes”

For both types 1 and type 2 diabetes, carbohydrate restriction is a great way to help control blood sugars and minimize the toxicity and expense of drug therapy. Here are some low-carb recipes from my book, Conquer Diabetes and Prediabetes.

Breakfast:  Mexican Scrambled Eggs

4 large eggs (50 g each)

1.5 tbsp (22 ml) olive oil

4 tbsp (60 ml) Pico de Gallo a la Rose (see my post of Jan. 5, 2013) or commercial picante sauce (having 2 g or fewer carbs per 2 tbsp)

salt and pepper

Whisk the eggs until smooth, add salt and pepper to taste; set aside. Heat the olive oil in a medium-sized frying pan then add the eggs and cook until done, scrambling now and then. Transfer to plate and top with 4 tbsp (60 ml) Pico de Gallo a al Rosa. Digestible carb grams: 6.

Lunch:  Low-Carb Chili

1 cup (240 ml) Low-Carb Chili (see below)

1 oz (28 g) almonds

Enjoy 1 oz of almonds around mealtime or later as a snack. Digestible carb grams: 13.

LOW-CARB CHILI

It’s spicy, but not hot spicy. Peeled and sliced cold cucumbers make a nice side dish. If your children or housemates aren’t eating low-carb, they may enjoy the chili mixed 50:50 with cheese macaroni, and buttered cornbread on the side.

Ingredients

20 oz (567 g) raw ground beef, 80% lean meat/20% fat

20 oz (567 g) raw pork Italian sausage

1 large onion

14.5 oz (411 g) canned diced tomatoes

4 oz (113 g) tomato paste

1 tbsp (15 ml) dry unsweetened cocoa powder

5  garlic cloves

½ tsp (2.5 ml) salt

¼ tsp (1.2 ml) ground allspice

2 tbsp (30 ml) chili powder

¼ tsp (1.2 ml) ground cinnamon

½ tbsp (7.5 ml) ground cumin

¼ tsp (1.2 ml) ground cayenne pepper

2 packets (1 g per packet) Splenda tabletop sweetener

1 cup (240 ml) water

Preparation

Cut the Italian sausage into small pieces. Sauté the sausage, ground beef, onions, and garlic in a large pot. Don’t just brown the meat, cook it thoroughly. When done, drain off the fat if desired. Add the remainder of ingredients, bring to a boil, then simmer for about an hour. Add additional water if the chili looks too thick. Makes eight cups. Serving size is one cup (240 ml).

Nutrient Analysis:

Recipe makes 8 servings of 1 cup (240 ml). Each serving has 492 calories, 14 g carbohydrate, 3 g fiber, 11 g digestible carbohydrate, 24 g protein, 38 g fat. 10% of calories are from carbohydrate, 21% from protein, 69% from fat.

Notes: Analysis is based on fat not being drained from the cooked meat. Calorie count and calories from fat would be a bit lower if you drained off fat.

Dinner:  Shark and Broccoli

4 oz (110 g) shark, raw

2 cloves (3 g) garlic, peeled and diced

3 tbsp (45 ml) olive oil

1.5 cups (150 g) chopped raw broccoli

salt and pepper

6 oz (180 ml) dry white wine

Lightly salt and pepper the shark, then set aside. Sauté the garlic in 2 tbsp (30 cc) of the olive oil a few minutes over medium heat. Then add the broccoli and sauté to your preference, adding salt and pepper to taste. Remove to a dish. Add another 1 tbsp (15 ml) olive oil to the pan and sauté the shark at medium heat until done, careful not to overcook. Enjoy with dry white wine. Digestible carb grams: 11.

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December 2, 2013 · 6:32 AM

FDA Looking At Home Glucose Meter Accuracy

The Joslin Diabetes Blog has some details. For example:

Current standards for blood glucose meters were established by the FDA in 2003 in conjunction with the International Organization for Standardization (ISO). Today’s requirements state that a blood glucose system (meter and strips) must meet an accuracy standard of being within 20 percent of reference values (laboratory) for numbers at or above 75mg/dl and within 15mg/dl below 75 mg/dl.

The FDA has been working on revising the current requirements since 2010 and the ISO has already come out with new standards. Whether the FDA will accept the ISO’s recommendations or adopt a different set of standards only time will tell.

The article also mentions various factors that may affect accuracy, including temperature extremes, humidity, and altitude. The user manual that comes with the device should explain these.

 

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December 1, 2013 · 8:29 AM

Spend Time Outdoors (In Childhood) to Prevent Nearsightedness?

Steve Parker MD, paleobetic diet,

Should have spent more time outdoors

I bet that nearsightedness (myopia) is a relatively modern phenomenon. If you don’t see well, you’re more likely to get bitten by a poisonous snake or overcome by a predator that you should have seen coming. Or you simply trip and fall over obstacles, incurring cuts or fractures. In prehistoric times, these circumstances would lessen your chances of passing your genes on to the next generation. In other words, there was strong selection pressure in favor of good vision.

(For now, I’ll ignore the possibility that poor vision may have beneficial aspects. “Parker, you don’t see good. Stay here with the women while we chase down that ibex.”)

Steve Parker MD, eye chart, eye exam

My eyes are this bad

I’ve worn glasses since the 3rd grade and I’ve never been happy about it. OK…. worse things can happen!

According to an article at PopSci, I may have avoided myopia by spending more time outside when I was a youngster:

A team of Australian researchers recently reviewed major studies since 1993 of kids, myopia and time spent outdoors. They found more than a dozen studies, examining more than 16,000 school-age kids in total, that found children were more likely to be nearsighted or to develop nearsightedness if they spent less time outdoors. A few of the later studies also found that being outdoors protected even those kids who did a lot of near work or had myopic parents. The studies included kids living in Europe, the U.S., Asia, the Middle East and Australia.

Read the rest.

Steve Parker MD, paleo diet, paleobetic

Nubian ibex in Israel

So get your kids outside. They may even benefit just from the sunshine.

And for my fellow myopics out there, note that your risk of a retinal detachment is higher than average. By the time that usually happens, our children are already grown, so there’s little or no selection pressure against it.

Steve Parker, M.D.

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November 26, 2013 · 3:52 AM

Do Heated Buildings Cause Obesity? Does Cold Exposure Prevent It?

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Are heated buildings making us fat?

Dr. Stephan Guyenet thinks they might. It’s not so much central heat as it is failing to expose our bodies adequately to temperatures around 60° F (15.6° C) or lower on a regular basis. Here’s a human experiment Dr. G wrote about:

The second study went further, using a longer cold exposure protocol to investigate changes in fat mass among people with low brown fat activity at baseline (4).  Researchers exposed volunteers to 63 F (17 C) air for two hours a day over a six-week period; again I assume they were lightly clothed.  As in the previous study, they observed an increase in brown fat activity with cold training, and they found that calorie expenditure was higher when subjects were in the ‘cold’ air.  After six weeks of training, body fat mass had declined by about 5 percent.  This is despite the fact that all subjects were lean to begin with!

Read the rest.

I thought this study tied in with that one showing an inverse relationship between altitude and obesity. Environmental temperature rises roughly 3° F with every 1,000 feet (305 meters). But the altitude study controlled for (accounted for) temperature, meaning that the temperature had nothing to do with the association.

Somebody’s probably already tried to link environmental temperatures—whether inside the house or out—to obesity rates. Let me know if you find it.

—Steve

Addendum (after a little searching):

A few minutes at Pubmed.gov revealed this 2013 abstract:

Objective: Raised ambient temperatures may result in a negative energy balance characterized by decreased food intake and raised energy expenditure. This study tested whether indoor temperatures above the thermoneutral zone for clothed humans (approx. 23 o C) were associated with a reduced body mass index (BMI). Design and Methods: Participants were 100,152 adults (≥ 16 years) drawn from 13 consecutive annual waves of the nationally representative Health Survey for England (1995 – 2007). Results: BMI levels of those residing in air temperatures above 23 o C were lower than those living in an ambient temperature of under 19 o C (b = -.233, SE =.053, p <.001), in analyses that adjusted for participant age, gender, social class, health and the month/year of assessment. Robustness tests showed that high indoor temperatures were associated with reduced BMI levels in winter and non-winter months and early (1995 – 2000) and later (2001 – 2007) survey waves. Including additional demographic, environmental, and health behavior variables did not diminish the link between high indoor temperatures and reduced BMI. Conclusions: Elevated ambient indoor temperatures are associated with low BMI levels. Further research is needed to establish the potential causal nature of this relationship.

And consider this abstract, probably from the altitude study I mentioned:

http://www.ncbi.nlm.nih.gov/pubmed/23357956

“There was an approximately parabolic relationship between mean annual temperature and obesity, with maximum prevalence in counties with average temperatures near 18 °C [64.4° F].”

I don’t have the full article, but “parabolic” in this context probably means the obesity incidence was highest at 64.4° F, with lower obesity incidence both above and below 64.4°.

Of course, living in a particular environment doesn’t equate to exposing yourself to outdoor temperatures. But it makes sense that someone living in a cold environment will have more cold exposure than someone in a hot climate.

Perhaps 64.4° F is a sweet spot for efficient body temp regulation and energy partitioning. Living at temps significantly above or below that may cost you energy-wise: you expend extra calories maintaining a normal body temperature, tending to result in lower obesity incidence.

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November 22, 2013 · 8:30 AM

Should Diabetics Exercise?

 

Women, don't worry about getting too bulky with muscles: you don't have enough testosterone for that

Women, don’t worry that weight training will get you too bulky with muscles: you don’t have enough testosterone for that

Read on for the potential benefits of exercise, then decide for yourself.

GENERAL EXERCISE BENEFITS

Regular physical activity postpones death, mostly by its effect on cancer, strokes, and heart attacks.

Exercise is a fountain of youth. Peak aerobic power (or fitness) naturally diminishes by 50 percent between young adulthood and age 65. Regular exercise increases fitness (aerobic power) by 15–20 percent in middle-aged and older men and women, the equivalent of a 10–20 year reduction in biological age.

Additional benefits of exercise include: 1) enhanced immune function, 2) stronger bones, 3) preservation and improvement of flexibility, 4) lower blood pressure by 8–10 points, 5) diminished premenstrual bloating, breast tenderness, and mood changes, 6) reduced incidence of dementia, 7) less trouble with constipation, 7) better ability to handle stress, 8) less trouble with insomnia, 9) improved self-esteem, 10) enhanced sense of well-being, with less anxiety and depression, 11) higher perceived level of energy, and 12) prevention of weight regain.

EFFECT ON DIABETES

Eighty-five percent of type 2 diabetics are overweight or obese. It’s not just a random association. Obesity contributes heavily to most cases of type 2 diabetes, particularly in those predisposed by heredity. Insulin is the key that allows bloodstream sugar (glucose) into cells for utilization as energy, thus keeping blood sugar from reaching dangerously high levels. Overweight bodies produce plenty of insulin, often more than average. The problem in overweight diabetics is that the cells are no longer sensitive to insulin’s effect. Weight loss and exercise independently return insulin sensitivity towards normal. Many diabetics can improve their condition through sensible exercise and weight management.

Muscles doing prolonged exercise soak up sugar from the blood stream to use as an energy source, a process occurring independent of insulin’s effect. On the other hand, be aware that blood sugar may rise early in the course of an exercise session.

EXERCISE RECOMMENDATIONS

You don’t have to run marathons (26.2 miles) or compete in the Ironman Triathlon to earn the health benefits of exercise. However, if health promotion and disease prevention are your goals, plan on a lifetime commitment to regular physical activity.

Kayaking combines exercise and recreation

Kayaking combines exercise and recreation

For the general public, the U.S. Centers for Disease Control and Prevention recommends:

  • at least 150 minutes per week of moderate-intensity aerobic activity (e.g., brisk walking) and muscle-strengthening activity at least twice a week, OR
  • 75 minutes per week of vigorous-intensity aerobic activity (e.g., running or jogging) plus muscle-strengthening activity at least twice a week. The muscle-strengthening activity should work all the major muscle groups: legs, hips, back, abdomen, chest, shoulders, arms.

I’m working on a program of combined aerobic (high intensity interval training) and strength training for just 70 minutes a week, but it’s not yet ready for prime time.

STRENGTH TRAINING

What’s “strength training”? It’s also called muscle-strengthening activity, resistance training, weight training, and resistance exercise. Examples include lifting weights, work with resistance bands, digging, shoveling, yoga, push-ups, chin-ups, and other exercises that use your body weight or other loads for resistance.

Strength training just twice a week increases your strength and endurance, allows you to sculpt your body to an extent, and counteracts the loss of lean body mass (muscle) so often seen during efforts to lose excess weight. It also helps maintain your functional abilities as you age. For example, it’s a major chore for many 80-year-olds to climb a flight of stairs, carry in a bag of groceries from the car, or vacuum a house. Strength training helps maintain these abilities that youngsters take for granted.

According to the U.S. Centers for Disease Control and Prevention: “To gain health benefits, muscle-strengthening activities need to be done to the point where it’s hard for you to do another repetition without help. A repetition is one complete movement of an activity, like lifting a weight or doing a sit-up. Try to do 8–12 repetitions per activity that count as 1 set. Try to do at least 1 set of muscle-strengthening activities, but to gain even more benefits, do 2 or 3 sets.”

Look into "body weight training" if weight machines and dumbbells don't appeal to you

Look into “body weight training” if weight machines and dumbbells don’t appeal to you

If this is starting to sound like Greek to you, consider instruction by a personal trainer at a local gym or health club. That’s a good investment for anyone unfamiliar with strength training, in view of its great benefits and the potential harm or waste of time from doing it wrong. Alternatives to a personal trainer would be help from an experienced friend or instructional DVD. If you’re determined to go it alone, Internet resources may help, but be careful. Consider “Growing Stronger: Strength Training for Older Adults” (ignore “older” if it doesn’t apply).

Current strength training techniques are much different than what you remember from high school 30 years ago—modern methods are better. Some of the latest research suggests that strength training may be even more beneficial than aerobic exercise.

AEROBIC ACTIVITY

“Aerobic activity” is just about anything that mostly makes you huff and puff. In other words, get short of breath to some degree. Examples are brisk walking, swimming, golf (pulling a cart or carrying clubs), lawn work, painting, home repair, racket sports and table tennis, house cleaning, leisurely canoeing, jogging, bicycling, jumping rope, and skiing. The possibilities are endless. A leisurely stroll in the shopping mall doesn’t qualify, unless that makes you short of breath. Don’t laugh: that is a workout for many who are obese.

But which aerobic physical activity is best? Glad you asked!

Ideally, it’s an activity that’s pleasant for you. If not outright fun, it should be often enjoyable and always tolerable. Unless you agree with Ken Hutchins that exercise isn’t necessarily fun.

Your exercise of choice should also be available year-round, affordable, safe, and utilize large muscle groups. The greater mass and number of muscles used, the more calories you will burn, which is important if you’re trying to lose weight or prevent gain or regain. (Exercise isn’t a great route to weight loss in the real world, although it helps on TV’s Biggest Loser show.) Compare tennis playing with sitting in a chair squeezing a tennis ball repetitively. The tennis player burns calories much faster. Your largest muscles are in your legs, so consider walking, biking, many team sports, ski machines, jogging, treadmill, swimming, water aerobics, stationary cycling, stair-steppers, tennis, volleyball, roller-skating, rowing, jumping rope, and yard work.

You dog needs brisk walking, too

You dog needs brisk walking, too

Walking is “just what the doctor ordered” for many people. It’s readily available, affordable, usually safe, and requires little instruction. If it’s too hot, too cold, or rainy outside, you can do it in a mall, gymnasium, or health club.

MEDICAL CLEARANCE  

Check this link.

SUMMARY

All I’m asking you to do is aerobic activity, such as walk briskly (3–4 mph or 4.8–6.4 km/h) for 30 minutes most days of the week, and do some muscle-strengthening exercises two or three times a week. These recommendations are also consistent with the American Diabetes Association’s Standards of Care–2013. This amount of exercise will get you most of the documented health benefits.

Steve Parker, M.D.

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