The Heart Healthy Lifestyle:

The Prevention and Treatment of Type 2 Diabetes

Copyright © 2013 by Sean Preuss

Smashwords Edition

All rights reserved. Except as permitted under the U.S. Copyright Act of 1976, this book may not
be reproduced, distributed, or transmitted in any form or by any means, without the written
permission of the author.

Book name and logo are trademarks of The Heart Healthy Lifestyle, LLC.
This book is dedicated to Ali Elizabeth, Emily, Andrew, Brandon, Gillian, and Kevin, for the
hardships you’ve endured and the successes you’ll achieve.
 Acknowledgements

The Heart Healthy Lifestyle: The Prevention and Treatment of Type 2 Diabetes is the product of
a collaborative effort. I’m truly grateful for the contributions of each team member.

First and foremost, this project would not be possible without Valerie Demetros, the primary
editor. Valerie provided me with something that we all need in life: honest feedback. Throughout
the process of editing, Valerie was patient with the varying demands of my life. She also
provided valuable insights and experience from her long career as an editor/writer. It’s of no
surprise to me that Valerie has played a large role in the creation of several successful books,
and I’m sure that will continue to be the case.

I am fortunate to have additional editors during the refinement of this ebook. Having edited
several previous health books, Lynn Lancaster also brought valuable insights during the start of
the editing process. Dr. Helen Hilts is one of the leading primary care physicians and diabetes
experts in the United States. Despite having a thriving practice and many demands, Dr. Hilts
provided her time and effort to make sure the presented science is accurate.

Several individuals discussed their experiences with diabetes during lengthy conversations with
me. I am extremely grateful for their honesty; it will go a long way toward helping many others
who are concerned with diabetes.

The visual tables and graphs come from the work of Kelly Christiansen, a veteran of graphic
design. Kelly made this entire process easier by creating visual displays of data that were better
than what I had envisioned.

Cathryn Creno took two small actions that produced large effects. She introduced me to Valerie,
and she encouraged me to write this book during an off-hand conversation. It’s funny how
inspiration can strike in even the most casual of situations.

A big thank you goes out to all of my past and present clients. My clients are one of my largest
support teams, and several of the recommendations in this book are the products of our
successful experiments in the gym.

I was introduced to some of the research and concepts in this book by several of my graduate
professors at Arizona State University. ASU gave me a wonderful two years that I cherish from
career and personal standpoints.

There are three men who I consider to be my mentors in the health field: Fredrick Hahn, Dr.
Glenn Gaesser, and Dr. Ben Bocchicchio. Each has a different background, teaching style, and
even some conflicting philosophies, but all three provided me with learning experiences that are
invaluable.

Finally, I could not finish acknowledgements without thanking my biggest fans: my parents
(Roger and Susanna), stepparents (Anthony and Eileen), brothers (Stephen and Ryan), sisters-
in-law (Stephanie and Krista), and my closest friends, Marc and Andrew. My life is an ambitious
and eccentric journey in the pursuit of my dreams. Despite my unique path, you have
consistently demonstrated love and support, and for that I am eternally grateful.
 Contents

Chapter 1: Diabetes

Chapter 2: What is Diabetes?

Chapter 3: Medications or Lifestyle

Chapter 4: Implementing Change

Chapter 5: Strength Training

Chapter 6: Aerobic Exercise

Chapter 7: Active Sedentary Time

Chapter 8: Pro LiVe Meals

Chapter 9: Aids for Post-Meal Glucose

Chapter 10: Everything in Life is Feedback

References
 Medical Disclaimer

The suggestions provided in this book are research-based and have worked for case studies in
private practice as well as with research participants. However, the suggestions in this book are
not substitutions for a physician’s care and should not be taken as medical advice. All decisions
regarding your health should be made with your personal doctor. The suggestions in this book
may require simultaneous medication adjustments or may not be ideal for your specific health
circumstances. You and your personal physician should discuss and make the final decisions
on all of your health matters. The Heart Healthy Lifestyle disclaims any liability or warranties of
any kind that come from the use of this book. Always contact your personal physician with any
health troubles that arise.
 Chapter 1: Diabetes

The Heart Healthy Lifestyle

Key Terms

Beta cells-cells in the pancreas that produce insulin.

Fasting Blood Glucose-the measure of blood sugar in the morning, just after waking up. It’s
referred to as “fasting” because one is typically in a fasted state after a full-night’s sleep.

Glycogen-stored glucose in the liver and muscles.

Hemoglobin A1c (HbA1c)-a measure of average blood glucose over a three-month period.
Hemoglobin is another name for red blood cell, and hemoglobin A1c indicates what percent of
red blood cells are attached to glucose. This measure is a better representation of your general
blood glucose level than fasting blood glucose, but fasting blood glucose is effective for getting
a quick snapshot.

Insulin-the hormone that allows for glucose to move from the blood into cells to be used as fuel
or stored as fat or glycogen.

Insulin Resistance-condition that requires higher than normal amounts of insulin in the blood to
lower blood glucose. Insulin is attempting to help glucose enter cells, but the cells are resistant
to insulin’s efforts.

Insulin Sensitivity-the condition where cells are efficient at taking glucose. Cells are sensitive
to the actions of insulin. Therefore, little insulin is needed to reduce blood glucose.

Where will you be in 10 years?

You could go from working 9-5 to being a jet-setting retiree. In 10 years, your kids or grandkids
could go from nonexistent to playing on soccer teams, or from high school to starting families of
their own. In 10 years, you could change from single to married with children.

One decade can be the period that brings you from dreamer to achiever, from planning the life
you want to living the best life you could imagine.
However, if you have type 2 diabetes, you may not be able to count on those 10 years.

Type 2 diabetes can reduce your lifespan up to 10 years, according to the Williams Textbook of
Endocrinology (12th Edition) [35]. I don’t think anyone sees a decade as a trivial amount of time,
but if you have young children, grandchildren, or unfulfilled goals, then those additional 10 years
are invaluable.

In 2012, 22.3 million Americans were diagnosed with diabetes and now they are at risk for
seeing their futures shrink. Overall, diabetes is the sixth leading cause of death in the US [33].

Diabetes significantly compromises your quality of life and longevity.

The reach of diabetes, specifically type 2, doesn’t just stop at longevity. Quality of life is also a
target. Over time, diabetics can develop vision loss, nerve damage, and heart disease, which is
so prevalent with diabetes that it is the cause of death in 75 percent of diabetics [46].

Another important issue related to a diabetes diagnosis lands right in your wallet. Diabetes is
not a cheap disease. In fact, the United States spent $245 billion in 2012 on diabetes-related
expenses, including hospital and emergency care, physician visits, medications, unemployment,
and absenteeism due to diabetes-related issues.

But a diagnosis of diabetes doesn’t mean it’s time to throw in the towel. Your daily habits are
powerful enough to positively change your outcome.

Mark’s Story
It took a one-eyed Chihuahua to help one man see that he needed to change his life. Mark, a
55-year-old, self-employed, real-estate professional, and his wife, Meghan, adopted a
Chihuahua puppy, Milo, from the Humane Society.

“As a puppy,” Mark said, “Milo ripped up and destroyed stuffed animals. He would tear them up
until the stuffing was all over. Then it was my turn to pick it all up…and I would be out of breath!”

Milo’s destruction of stuffed animals wasn’t the only task Mark struggled with. “Small tasks were
difficult. I had to use a knee-high wall to put my foot on so I could reach down and tie my shoes.
I even changed how I put my shoes and socks on. Really, for me, I could tell something wasn’t
right. I knew I needed to lose weight. Diabetes? I never thought about it.”

Although Mark’s struggle to pick up a torn stuffed toy was a testament to his lack of fitness, his
biggest problem was his blood glucose. You can’t really feel your blood glucose like you can
feel the struggle associated with picking up items off the floor or simply moving boxes around.
His struggles with small tasks helped Mark realize that there was a much larger problem at
hand.
 Blood Glucose Values

Mark knew something was wrong and his concern was validated. His hemoglobin A1c, a three-
month measure of blood glucose, was measured at 7.2%. Healthy blood glucose is considered
anything below 5.7%. His morning blood glucose numbers ranged from 128-135 mg/dl, whereas
healthy blood glucose falls between 65-99 mg/dl. His doctor diagnosed him with type 2
diabetes.

In addition, Mark, who is 6’6” and a naturally lean guy, reached a peak weight of 305 pounds,
which classified him as obese. With the extra weight, low energy, and lack of fitness efforts, it’s
no wonder his daily tasks became challenging.

Within one year of diagnosis, Mark struggled with neuropathy, a type of nerve damage that
leads to a loss of sensation in the hands or feet and ultimately leads to amputation for many
diabetics.

“My feet were burning and painful,” Mark said. “Every day, my feet hurt during the day and at
night, it was unbearable: the burning, freezing cold, tingling, then sharp pains at times. Every
day.”

Along with the increasing awareness of his daily activity struggles, the turning point for Mark
was a routine visit with his physician, Dr. Helen Hilts. Although he made minor dietary changes
since his diagnosis a few years prior, only small improvements were measured in his morning
glucose. During one important visit with Dr. Hilts, she told Mark point blank that if he did not
make major changes within the next 30 days, he would begin daily insulin injections.

“I thought about sticking needles in my belly,” Mark said. “It scared me because I never liked
needles. I was shocked, it was no longer something I could keep ignoring.”

Mark changed his lifestyle significantly. He began to eat better with advice from Dr. Hilts (see
Chapter 8). He started exercising for 15 minutes, twice per week (see Chapter 5). He also made
a simple change to his relaxation time (see Chapter 7).
One year later, Mark is energetic and in need of a new wardrobe. His hemoglobin A1c is at
5.2% and his morning blood glucose ranges from 85-95 mg/dl. Both numbers fall below
prediabetic and diabetic levels. He also weighs 250 pounds, which is a 55-lb. loss overall.

“Because of this journey, little things like Milo ripping up stuffed animals don’t bother me,” Mark
said. “The other day I parked in a parking garage. I had to go up two flights of stairs and instead
of waiting for the elevator; I took the stairs, going up two at a time. Boom-boom-boom-boom—
up to the top! I came around the corner, was going to my car and stopped, literally stopped, in
the middle of the parking lot and said to myself, ‘I’m not breathing heavy.’ I couldn’t do that
before. I would have been panting and out of breath.”

Even the neuropathy improved and Mark only gets the burning sensation in his feet about once
or twice a month. The numbness occurs so rarely that he doesn’t even think about it anymore.
Despite the results of a genetic test indicating that Mark has a predisposition for developing
neuropathy, his lifestyle adjustments have changed the symptom frequency from every day to
roughly every 30 days.

Getting off the couch used to be a chore for Mark. Now he’s considering taking up even more
physical activity, such as walking and hiking.

Connecting Mark’s Story to Yours

The simple fact is that type 2 diabetes significantly increases your risk of having a heart attack
and dying prematurely. And that’s not all. Type 2 diabetics make up nearly half of Americans
who suffer from late-stage kidney disease [8]. They also suffer from significant nerve damage
that often leads to partial or complete blindness. With regard to neuropathy damage, almost
two-thirds of amputation cases in the United States are type 2 diabetics [8].

Now, this doesn’t mean it’s time to throw your hands up and surrender. Yes, if you become
diabetic, you are diabetic forever. But the good news is that you can restore your blood glucose
to a healthy, non-diabetic level. Your blood glucose is the key when it comes to the risk of facing
all of the horrible outcomes mentioned above.

Almost two-thirds of amputation cases in the United States are type 2 diabetics.

Mark is an example of a diabetic who returned to a healthy blood glucose range, and he noticed
changes in his morning blood glucose in less than 30 days. A few adjustments, especially the
ones advocated in The Heart Healthy Lifestyle, can improve your health in just a matter of a few
weeks.

Perhaps the most positive aspect of type 2 diabetes is that it can be treated largely with simple
changes to your lifestyle. Many studies have shown lifestyle changes can effectively reverse
several key aspects of diabetes. For those of you who are already on medications for diabetes,
changing your lifestyle could greatly decrease your reliance on those medications. (Consult your
doctor about adjusting your medications as you start the recommendations found in this book,
especially with dietary changes).

The Heart Healthy Lifestyle: The Prevention and Treatment of Type 2 Diabetes is designed to
do exactly that: treat your diabetes through research-tested and proven methods that are safe,
healthy, sustainable, and also decrease the need for medications.

How to Use The Heart Healthy Lifestyle

I have written this book with specific chapters in mind, and each one discusses one important
change toward a healthier lifestyle. Every chapter presents research regarding the next change
you can make, the benefits of the change, the minimal amount to be effective, and the best way
to apply the change.

In each chapter, I offer you a challenge that brings you closer to your goals and helps you
realize those goals, one step at a time. The challenges get you ready for your new lifestyle
habits. By accomplishing these tasks, you will outline motivations for change, boost your
confidence for making changes, establish a support group that will help you along the way, and
attain necessary resources. The challenges are optional, but I HIGHLY recommend accepting
each challenge. As a whole, the challenges will make your adoption of The Heart Healthy
Lifestyle’s recommendations much easier.

People generally regret what they don’t do more than what they actually do.

The Heart Healthy Lifestyle is NOT a program or diet book. I am not advising you to quit your
current lifestyle immediately and begin living a completely different way. This book serves as a
buffet of options for you to choose from. Consider the choices and implement them as you
desire. Of course, the more you implement, the better your results will be. At a minimum, I
recommend adopting one of the exercise recommendations from Chapters 5 or 6, along with
some of the dietary changes from Chapter 8.

My goal in writing this book is to present the best information out there, and practical methods
for aligning with your ideal self: the ideal vision of how you want to live your life.

Moving forward, I have just one request - be assertive in the pursuit of optimal health, a better
quality of life, and a longer life. People generally regret what they don’t do more than what they
actually do, and I believe that being assertive in the pursuit of your health will eliminate those
regrets.

Challenge 1: Imagine Your New Life

At the end of each chapter, I will suggest a task that will help you to begin your new lifestyle
habits. To start with, let’s imagine your new life. Since you’re reading this book, it’s likely that
you desire a life somewhat different than the one you have now. Mentally, put yourself in that
new life. What is different? Are you taking fewer or no medications? Are you stronger, leaner, or
have a higher energy level?

What is important about the changes you desire? Do you want to feel better and have more
energy right now? Do you want your blood sugar to improve so you will be around to spend time
with your spouse, children, or grandchildren? Will improving your health or fitness enable you to
take that hike or vacation that you’ve always desired?

Start by writing these desires down. I don’t care if it’s a list of one or 100 items. Write them down
so you can look at the list for a periodic reminder of your purpose. It’s important to not only know
what you are trying to accomplish, but also why you are trying to do it.

Once you have determined what you want from The Heart Healthy Lifestyle, and more
importantly, WHY you want it, then you are ready to move forward. Let’s begin the journey…
 Chapter 2: What is Diabetes?

Before you drive a car, you need to know the basics prior to jumping behind the wheel. Using
the same reasoning, before you can understand your health and any changes to your lifestyle,
you need to have a solid understanding of diabetes. Let’s get started.

What is Diabetes?
In a healthy system, carbohydrates and, to a much lesser extent, proteins are broken down to
glucose during digestion and that glucose is released into the bloodstream. Glucose is important
because it is one of the fuels that our cells use (along with fat and ketones).

Your body can actually sense when food is coming. Before taking the first bite, the Beta cells of
the pancreas secrete insulin into the blood. When blood glucose rises above the normal level, a
much greater amount of insulin is secreted. Glucose then enters cells through the glucose door
on the cell wall. Insulin is the key that unlocks the door, allowing glucose to enter.

Muscles can use glucose for immediate energy or store it as glycogen or fat. If glucose could be
considered a folding chair ready to be sat on, glycogen is folding and stacking the chairs.
Folding chairs are more spatially efficient and easy to stack, but unfortunately you cannot use
them when folded and stacked.

During strenuous activities such as strength training or a sprint-like effort, muscles need more
glucose for energy. For that glucose, muscles can access and breakdown their own glycogen
stores for conversion to glucose. The liver also stores glucose as glycogen, although the
capacity for glycogen storage is about a third of the muscles’ capacity. The liver breaks down its
glycogen stores on the (hopefully) rare occasions that blood glucose is low.

To recap:

1. You eat food.

2. The food (mainly the carbohydrates) is broken down to glucose.

3. Glucose is released into your bloodstream, increasing your blood glucose level.

4. The Beta cells of the pancreas release more insulin (this process actually starts before
eating).

5. Insulin unlocks the door, allowing glucose to enter cells, which are eager to take glucose
(a state called “insulin sensitivity”).
 6. If the glucose isn’t used immediately, it is converted to glycogen, which is the storage form
of glucose (recall that muscles can store about three times as much glycogen as the liver).

That is the rundown of a healthy system. In a diabetic system, the first three steps are the same.
After that, everything goes awry.

The precursor to diabetes is an interruption to step 5, which is called “insulin resistance.” Insulin
resistance is the opposite of insulin sensitivity. Fewer glucose doors on cells are available.

To make up for the lack of efficiency in getting glucose into the cells for storage or fuel use, the
Beta cells start producing more insulin. Excess insulin is needed simply to maintain a healthy
blood glucose level. The production of extra insulin leads to a few problems.

First, the extra insulin pushes glucose into storage as fat, increasing total body fat. Also,
prolonged periods of excess insulin production lead to an issue with step 4: Beta cell “burn out.”
Basically, the Beta cells stop working (and many die) after being in overdrive for so long. As
they burn out, your Beta cells produce less insulin and you lose the ability to compensate for
insulin resistance. Therefore, blood glucose increases and diabetes is the eventual diagnosis.
By the time a person is diagnosed with diabetes, as many as 50% to 60% of Beta cells have
already died.

To summarize the diabetic dysfunction, the road to diabetes starts with a disturbance to step 5:
cells turn glucose away more often. To make up for the lack of efficiency, the Beta cells produce
more insulin, which eventually leads to a problem in step 4: the Beta cells slowly lose their
ability to produce insulin. As the latter occurs, blood glucose rises.

Technically speaking, type 2 diabetes mellitus, or hyperglycemia, is diagnosed via one of three
ways. First, it can be diagnosed when morning blood glucose (a.k.a. “fasting blood glucose”) is
measured on two separate occasions at or greater than 126 mg/dl. Second, diagnosis occurs
when one measurement of blood glucose is at least 200 mg/dl and if symptoms of diabetes
exist. Finally, diabetes can be diagnosed when hemoglobin A1c (HbA1c) is 6.5% or greater.

HbA1c is a more cumulative measure of blood glucose, taking the average blood glucose over a
three-month span as opposed to the current moment. The measurement of HbA1c is the
percentage of total hemoglobin that has glucose attached. Hemoglobin is a protein responsible
for carrying oxygen through the blood. Sacks of hemoglobin make up almost all of the dry
material found in red blood cells.

We will look at studies measuring both fasting blood glucose and HbA1c.

The Diabetes “Benefits Package”

For those who suffer from type 2 diabetes, managing the disease can be a full-time job. Poorly
controlled or severe diabetes requires balancing an assortment of medications, paying close
attention to diets, and monitoring blood glucose levels at various times in the day including after
each meal. However, if controlled with nutrition, exercise, and other lifestyle changes, the
disease is much simpler with few complications.

Like a full-time job, having type 2 diabetes comes with a “benefits package” of its own. Instead
of receiving 401(k) or IRA contributions for the eventual outcome of retirement, diabetics who
don’t manage the condition receive nerve damage that can lead to blindness and limb
amputation. Instead of health insurance, there is an assurance of a greater risk for
hypertension, gum disease, kidney failure, heart disease, chronic pain, erectile dysfunction, and
premature death.

Heart disease is the pinnacle of the diabetes “benefits package.”

Heart disease is the pinnacle of the diabetes “benefits package.” Diabetics are anywhere
between two to four times more likely to die from heart disease. As mentioned in Chapter 1,
every 1% increase in HbA1c is associated with an 18% risk increase for a heart attack or other
event related to heart disease [46]. In addition, there are several other scary outcomes for
diabetics:

• Hypertension (high blood pressure). Hypertension is diagnosed when systolic blood

pressure (the first number) is measured at or above 140 mmHg on two occasions, or at
least 90 mmHg for diastolic blood pressure (the second number) on two occasions. High
blood pressure can lead to hardening of the arteries, an enlargement of the heart, or a
narrowing of blood vessels in the kidneys. Those changes increase risk for heart disease,
stroke, and kidney failure.

• Diabetic retinopathy. Extremely high blood glucose damages ocular nerves, resulting in
impaired vision, and, in some cases, complete blindness. Diabetic retinopathy is the leading
cause of blindness among people 20 to 64 years old [19]. About one third of type 2
diabetics have diabetic retinopathy [54]. The longer you have diabetes, the greater the risk
of vision deterioration. In fact, people who have diabetes for at least 10 years have nine-
times the risk of retinopathy when compared to people with diabetes of less than three
years. Diabetics with retinopathy also have almost four-times the risk for a lower-limb
amputation, according to a study published in Diabetes Care [34].

• Neuropathy. This is nerve damage that ultimately results in a loss of sensation in the
hands or feet. As mentioned in Chapter 1, Mark struggled with neuropathy in his feet. Day
and night, Mark’s feet alternated through a series of sensations including burning, extreme
cold, tingling, and sharp pains. Nerve damage, combined with the clogged arteries from
poor blood glucose control, is largely why more than 60% of amputations in the U.S. are in
people with diabetes [8]. A study published in Diabetes Care estimated type 2 diabetics to
have a 20-fold risk for an amputation [37].
 Neuropathy is detrimental for a few important reasons: When nerve damage occurs,
diabetics often miss minor injuries to the limbs (due to lack of sensation) that result in ulcers
and infections. Also, high blood glucose may inhibit internal defenses against infections,
leading to gangrene and the need for amputations. Regardless of a person’s weight and the
status of other heart-disease markers, another study in Diabetes Care indicated that blood
glucose is the major predictor for a person’s risk of lower-limb amputations [34]. The
duration of diabetes also increases the risk of a lower-limb amputation, even if blood
glucose is not very high above the diagnosis threshold.

• Erectile dysfunction. Despite being treated with diabetes medications, the results of a
study in The Lancet found that roughly half of middle-aged diabetic men suffered from
impotence [50]. Sadly, having poorly controlled diabetes is a definite buzz kill to a man’s
love life. (The good news is that good control of blood glucose improves this problem.)

• Nephropathy (kidney disease). Diabetics make up about 44% of new cases for end-stage
renal disease (meaning dialysis is required) [8]. Research in The New England Journal of
Medicine indicates the prevalence of kidney disease is strongly linked to a person’s HbA1c
over time; the greater HbA1c is, the greater the chances are of suffering from nephropathy
[45]. Also, as mentioned before, diabetics often develop high blood pressure, which
narrows blood vessels in the kidneys. That structural change is another way diabetes
increases the risk for kidney disease and, ultimately, kidney failure.

Not only does type 2 diabetes possibly lead to the above conditions, diabetics are also most
likely to experience hypoglycemia (low blood glucose). This occurs because diabetics may
overproduce insulin in response to a high-carbohydrate meal or due to an injection or dosage of
too much insulin or other blood glucose medications. Hypoglycemia occurs when blood glucose
falls below 60 mg/dl. Basic signs are irritability (think about how you feel when missing a meal),
fatigue, weakness, and a headache. In extreme cases, hypoglycemia can cause brain damage
and death.

On a positive note for type 2 diabetics, there are options for medications and lifestyle changes.
In the next chapter, we discuss the common medications used and how they compare with
lifestyle changes.

Challenge 2: Your Support Team

Why go down this journey on your own when you can have company? Almost every new
experience in my life, from moving across the country to sky diving, has been a group effort.
When moving across the country, friends joined me for the road trip while family members
helped me find the cheapest ways to ship my belongings. Employees of the skydiving company
provided me with instructions and a professional tandem partner when I took that jump.
The same can be said for Mark. Dr. Hilts and Mark’s wife, Meghan, played huge roles in holding
him accountable to his lifestyle changes and health. In a positive manner, they provided him
with support. Mark even admits that his changes wouldn’t be possible without them.

Who makes up your social-support team? Write a list of friends, family, coworkers, and health
professionals with whom you can discuss what you want to achieve, the specific changes you
will make, and your journey to achieving your goals. A health professional, such as your primary
care physician, is a great person to tell, as you will require his or her help with advice and
potentially adjusting medicines as you implement recommendations from The Heart Healthy
Lifestyle: The Prevention and Treatment of Type 2 Diabetes.

Overall, I recommend choosing individuals who will listen and support you rather than judge,
talk to you when you encounter speed bumps, and help you take constructive and positive
lifestyle actions.

Keep that list of your potential support group handy. You will need it later.
 Chapter 3: Medications or Lifestyle

Typically, the go-to treatment for type 2 diabetes is medicine. Unfortunately, that seems like the
easy way to go: why change lifestyle habits, the habits that may have a role in the onset of
diabetes, when you can remain in your comfort zone by continuing the same habits and just
take a pill?

The simple answer is that medications are effective and sometimes necessary, but they do
come with side effects and they cannot provide good control of diabetes unless other changes
are made (diet, exercise, etc.). Some popular diabetic medications are Metformin, Sulfonylureas
(SU), and Insulin. Here’s a brief breakdown of what they do, the changes they can cause, and
potential side effects of each.

1. Metformin
Metformin works by decreasing the amount of glucose produced by the liver and also increases
insulin sensitivity [43]. It typically lowers blood glucose by 20%, HbA1c by 1.5%, and also helps
with weight loss. Potential side effects include abdominal pain, diarrhea, excess gas, nausea,
vomiting, impaired absorption of vitamin B12, and a loss of appetite.

2. Sulfonylureas (generic forms: chlorpropamide, glimepiride, glipzide, glyburide,

tolazamide, and tolbutamide)
Sulfonylureas (SU) has been the mostly widely used drug for type 2 diabetes. SU works by
stimulating the Beta cells in the pancreas to produce more insulin following a meal [43]. SU can
decrease blood glucose by about 20% and HbA1c by 1% to 2%. Research published in The
Lancet indicates that the blood glucose advantage SUs provide over basic dietary
recommendations may wear off in less than 10 years [51]. During that same time period, people
taking SUs gain an average of five pounds and have a 9-to-15 times greater risk of having a
hypoglycemia episode than those following basic dietary recommendations. SU doesn’t work if
your Beta cells are completely “burned out,” meaning they can no longer produce insulin [43].
Additional side effects include nausea, skin reactions, and congestive heart failure. On the
bright side, taking SUs lowers the risk of eventually developing diabetic retinopathy [51].

3. Insulin
Insulin is critical for type 2 diabetics who have worn out their Beta cells due to long-term
overuse. As discussed before, insulin has the critical role of unlocking cell doors so glucose can
leave the blood and enter cells. Insulin taken by diabetics comes in many different forms (some
similar to insulin produced in the body, and others molecularly modified). Like SUs, side effects
include weight gain and hypoglycemia. However, a Lancet study reported that when compared
to taking SUs, people on insulin gain three to five pounds more over a 10-year span and have a
two-to-three times greater risk of suffering a hypoglycemic episode [51]. Hypoglycemic episodes
are especially common with taking insulin when following meals high in carbohydrates. The
good news is that a study in the New England Journal of Medicine indicates that controlling
blood glucose through intense Insulin therapy decreases the risk for diabetic retinopathy, kidney
disease, and neuropathy [45].

Explore all other options for improving your health before asking your doctor to write a
prescription.

Lifestyle vs. Medications

Explore all other options for improving your health before asking your doctor to write a
prescription. At the very least, why not find out what your options are?

Thankfully, there are many options. Let’s look at a study that took middle-aged men and women
who were prediabetic (average fasting blood glucose of 105 mg/dl) and changed the lifestyle
habits (diet and exercise) for one group (LS), gave another portion Metformin (MED), and left a
control group with no change in their habits (CON) [12].

The Diabetes Prevention Program, published in Diabetes Care, tested these people before and
after a three-year period where they stuck to one of the three programs described above. The
rate of diabetes diagnoses per 100 years of combined living in each group is shown by various
age groups in the graph below:

At the end of the three years, the MED group reduced the development of diabetes by 31%
when compared to the CON group. However, the LS group reduced diabetes development by
58%. What’s more impressive is less than two-thirds of the LS group actually reached the
requested minimum of 150 minutes of physical activity per week. Essentially, the LS group was
adequate, at best, in fulfilling a major component of the desired lifestyle change, and they were
still 27% more effective than people taking medications for preventing diabetes. Taking this
route to diabetes prevention was especially effective in people over 60 years old.

This study wasn’t an aberration. Whether separated or combined, diet and exercise programs
produced 34% to 46% reductions in diabetes prevalence in high-risk men and women in China
[42].

The results of the Diabetes Prevention Studies led me to two critical conclusions:.

1. Improving your lifestyle is a very effective way to prevent diabetes, even when diabetes is
on your doorstep and banging on the door.

2. If changing your lifestyle can treat or prevent type 2 diabetes, then it stands to reason that
your lifestyle can cause diabetes.

Both conclusions above are empowering. If diabetes were completely a matter of genetics or
some other transcending factors, then we wouldn’t see the skyrocketing rates of diabetes in the
last 20 years. Also, this book and all other efforts to prevent or treat diabetes would be wastes
of time. You would be tied securely to the diabetes track with no way to stop the speeding train.

Lucky for you, that is not the case. You have a LARGE say in the matter: You have the power to
walk off the tracks. You have the power to choose your outcome when it comes to diabetes.
You can choose to be the control group and continue your previous path, or you can decide to
put the percentages in your favor by improving your lifestyle. I would much rather run off the
tracks than take my chances just sitting there.

You have the power to choose your outcome when it comes to diabetes.

It’s the Extra Weight…Right?

“I need to improve my health, therefore I need to lose a few pounds.”

I cannot tell you how many times I have heard that statement. We’ve all seen news segments
and documentaries discussing America’s epidemic of heart disease or type 2 diabetes while
showing extremely obese people walking down the street. The fact is that we’ve been
brainwashed to see the connotation between the two: if you are obese, you are not healthy. If
this were true, then it would stand to reason that all obese people are less healthy than all thin
people.

About one-third of Americans are obese [18], and more than 22 million Americans developed
diabetes in 2012 alone, but is there a connection between the two? Does improving your health,
and specifically your blood glucose, require the number on the scale to drop?

The best way to answer that is by looking at the research with those who have diabetes:
 • If fat is the answer, then losing fat without changes to your lifestyle should improve your
health, right? How does one lose fat without a change in lifestyle? One method is
liposuction. An average of 22 pounds of fat was removed from 15 obese women in a study
published in the New England Journal of Medicine [31]. Seven of the women were diabetic.
When the women were reassessed 10 to12 weeks after the procedure, the diabetic women
lost an additional pound of fat, totaling 23 pounds lost from before the procedure. However,
and this is a big however: NO changes were noticed in insulin sensitivity, blood glucose,
blood pressure, cardiovascular inflammation, or blood lipids (cholesterol). In other words,
the diabetic women were thinner but not healthier.

• Obese and diabetic men and women with an average age of 66 exercised twice a week for
45 minutes at each workout in a study at Tufts University [6]. At the end of 16 weeks, the
trainees decreased their HbA1c from 8.6% to 7.6%, which is a huge change. Also, their
average fasting blood glucose decreased 10%. However, no weight change occurred.

• The HERITAGE Family Study had men and women in their mid 30s exercise for roughly 30
to 50 minutes per day, three times per week, for 20 weeks [5]. At the end, the trainees
improved their insulin sensitivity and decreased the amount of insulin in their blood (a
positive sign). Here’s what didn’t change: their weight.

• Diet recommendations were given to a group of diabetics at the start of a 22-month study in
Sweden [40]. Those given the diet recommendations started with an average HbA1c of 8%.
At the end of the study, the average decreased to 6.9%, with several achieving an average
of less than 6%. The subjects lost an average of 18 pounds. However, the weight loss was
not linear with the HbA1c improvement, and the statistics showed that there was no
correlation between the two; the blood glucose changes occurred separately from the
weight changes.

Although I may have dashed your hopes in thinking all you had to do was lose weight and you
were home free, this doesn’t mean it’s not a good idea to lose weight while getting healthy. As in
Mark’s story from Chapter 1, he had a huge weight loss in addition to a glycemic rejuvenation.
Like Mark, it’s a good idea to improve your physique and fitness so that daily activities become
easier. Dropping 55 pounds dramatically increased the quality of Mark’s life. In general,
diabetes commonly occurs with obesity.

When it comes to improving your health, your lifestyle is the key factor.

However, weight/fat loss is not the mechanism that drives blood glucose changes. When it
comes to improving your health, your lifestyle is the key factor. If you make changes to your
lifestyle, your health will improve, regardless of what happens with your weight.

In addition to Mark, many people lost weight during the studies that are cited in this book.
However, weight loss is a side effect of the lifestyle improvements. The direct targets of the
lifestyle changes are your health measures: blood glucose, hemoglobin A1c, and insulin
sensitivity. Your health and longevity have the strongest ties with your lifestyle habits, NOT your
weight. Regardless of what happens with it, if you internalize and adopt the changes suggested
in this book, your health will improve. Consider weight loss a huge bonus.

Challenge 3: Visiting the Gym

Sometimes the most difficult part of getting started is merely showing up. Well, let’s show up.

Step one is simple: visit a local gym and look around. Typically, a gym employee highlights all
that the gym has to offer, and some of the resources available could be very useful in your
efforts to prevent or treat diabetes. There is no need to sign up or make any commitments on
your first visit and many gyms will offer a few weeks of free visits for you to give it a try.

Ultimately, I strongly recommend taking the plunge and joining a gym. They offer an abundance
of resources that are just not possible in a home gym. While you can fulfill the exercise
recommendations in Chapter 5 through home-based adaptations, visiting a gym minimizes the
need for equipment at home and makes it easier to attain your desired benefits.

You may be concerned that you are inexperienced in the gym, or you may be worried that
others will judge you. I have spent more than 13 years working in gyms and for most people, the
gym is a place of self-improvement. That means they are more focused on themselves rather
than what you are up to.

As far as expenses go, you won’t know the truth until you show up and ask. Don’t decide
against it completely until you’ve seen all the options, including business discounts, senior and
student discounts, and even seasonal discounts. Many large chains offer monthly rates less
than $20 per month. If necessary, visit a few gyms to figure out what is most convenient, cost-
efficient, offers the best equipment, provides the best atmosphere, or adequately addresses
whatever factor is most important to you.

If you are considering a home gym, call a company that has equipment you are interested in
(Bowflex, Total Gym, etc.) and ask questions. If you are unsure of what to ask, find out if the
product comes with a home-workout DVD or instruction manual.
 Chapter 4: Implementing Change

From this point forward you will find the how, what, and why of improving diabetes via specific
lifestyle changes. While the following chapters will address what and why, this chapter helps
prepare you for change. Specifically, this chapter will help you find out where you are and then
give you the tasks that increase your readiness to change.

First, ask yourself how ready you are to make a change, or changes, to your lifestyle. Choose
which answer below fits best, and then skip to the following section that corresponds with your
answer. To truly help with your process of making a change, read and partake only in the tasks
that are in your answer section. Once you’ve read the correct section, skip ahead a few pages
to the section titled “A Key Concept in The Heart Healthy Lifestyle,” where we’ll continue our
journey together.

1. I’m not ready to make changes within the next several months.

2. I want to make changes within the next few months.

3. I am ready to make changes.

4. I have already started making changes.

5. I made changes months ago and am planning to continue.

We all want to change under our own control and at our own pace.

1. I’m Not Ready to Make Changes within the Next Several Months
Perhaps you are reading this book with some curiosity but don’t want to or don’t feel you are
ready to make changes right now. Maybe someone is making you read this book. (If that’s the
case, please tell that person I said, “Thank you.”) If you are feeling forced to read The Heart
Healthy Lifestyle, I don’t blame you for resisting change. We all want to change under our own
control and at our own pace. I am not going to try to talk you into changing. You may have a lot
going on in your life and right now, addressing diabetes or prediabetes just doesn’t fit in.

Even Mark, our friend from the opening chapter, didn’t change immediately when diagnosed
with diabetes. Eventually, he reached a point where the importance of changing became
imperative and he no longer wanted to become winded by picking up pieces of a stuffed animal.
Even though he no longer wanted negative feedback from his blood work, that transcendent
desire to change his health wasn’t instant.
Here’s what I recommend for you at this point:

• List pros and cons for changing your lifestyle habits. What would you like to achieve as
a result? What seems unattractive about improving the way you live your life? Your pros
should include your vision for the future and what life would be like as a result of these
lifestyle changes.

• Think about when you changed your habits for the better. It doesn’t matter what the
habits were or how long the changes lasted. It could be that you read more, ate differently,
took more walks, called your friends and family more often, etc. Think about an instance or
two where you were successful with a change and then ask yourself exactly what was the
driving force that made you change? Why were you successful in adopting or sustaining the
new habit?

• Put your answers to good use. With regard to your cons in the list above, consider how
significant they are. Would each con largely impact your happiness in a negative manner?
Are the cons more negative than the pros are positive? If there are major cons that cannot
be changed, then how could you work around them? For example, if you are worried about
losing family time, exercise while your family is working or sleeping. If you enjoy eating a
food that negatively impacts your diabetes, then set aside a time once or twice a week
where you will still indulge. Think about your past successes and harness the underlying
factor that led you to be successful. Were you motivated due to an upcoming or ongoing
event (wedding, a vacation, etc.)? If so, plan an event that will lead you to act. Perhaps you
were successful in the past because you were more organized due to a busy schedule. If
so, get involved in a club, work activity, or sports league that will keep you focused and
active.

2. I Want to Make Changes within the Next Few Months

If this is how you feel right now, you may not be ready to make changes but you are interested
in eventually taking that leap. Bravo. Everyone who improves his or her lifestyle goes through
this stage at some point. Reading The Heart Healthy Lifestyle may be the start of your change-
planning process, for motivation, or to find ways around your perceived barriers. If this is the
case, I recommend the following:

• List the pros and cons for changing your lifestyle habits. Visualize the pros, the
potential benefits, as if they have already happened. Now list the cons to changing your
lifestyle. Write everything down and set it aside for a bit. Add to the list if you think of
anything before you take the next step.

• Look in your closet. Some of the recommendations in this book involve physical activity
so that means it’s time to take a look in your closet for suitable workout clothes. Do you
have shoes comfortable to walk in? This may be the first change you need to make. The
shoes don’t need to be $150 or endorsed by a famous athlete. They simply need to be
 comfortable enough to walk in. Your next step is to buy workout clothes and shoes for at
least two days of exercise per week.

• Assess your pros and cons. It’s time to return to your list above. First, visualize the pros
as if they have already happened. How does it feel to be at that point? How important are
those benefits? With regard to the cons, are they absolute roadblocks or merely speed
bumps? In other words, how can you work around those potential challenges? Are they
really as daunting and impossible as they seem? Now compare your pros and cons. Which
are more important to you? If your pros are, that’s a good sign that you are ready to start
taking action. If your cons are more important, how can you work around them? For
example, if you are uninterested in taking walks, create a song list of your favorite tunes on
your iPod that will take your mind off the walk.

3. I Am Ready to Make Changes

If this is where your mind is right now, it’s time to get ready to make a few changes. At this point,
you could be inching closer to getting started and excitement is building. Reading The Heart
Healthy Lifestyle is the first step in grabbing that motivation to get going, and it can help you
plan those specific changes. I suggest you:

• Look in your kitchen cabinets and refrigerator. Examine each item that you eat on a
regular basis (at least twice a week). Does it contribute positively or negatively toward your
ideal self? List the foods you believe are positive contributors to healthful eating habits
(Chapter 8 will help with this). I am a big advocate of focusing on your strengths versus
trying to improve your weaknesses. In this case, buy more of the foods you consider to be
positive contributors to your ideal self.

• Evaluate what makes you hesitant to develop new lifestyle habits. How significant are
these, and more importantly, how can you work around these barriers? Brainstorm. For
example, if finding the time to work out is keeping you from a consistent workout schedule,
plan shorter workouts (e.g. 10-minute walks) or less frequent workouts (e.g. strength
training only on Mondays and Fridays). Get up a little early and take a short walk in the
morning before breakfast, take a walk during lunch with a coworker, or even jog in place
while watching your favorite TV show.

4. I Have Already Started Making Changes

Congratulations. Making changes and developing consistency with these changes is your first
step toward a healthier you. You have surpassed the huge hurdle of getting started. If you
recently started, you are probably reading this to support your new habits, deal with a lapse, or
for even more motivation.

With regard to the lapses that occur, don’t worry. Everyone slips up occasionally. For example,
if you are eating more fruits and vegetables in place of frequent desserts, you may break down
and indulge in a bit of chocolate cake. It’s human to experience such lapses. Regardless of
what happened, keep moving forward. If this is where you are right now, ask yourself the
following:

• What benefits have I noticed? List the benefits you have enjoyed after making changes.
Examples of these can be more energy from a walking routine, more alertness at work due
to morning exercise or even less bloating because of a change of eating habits.

• What did I learn from any lapses I’ve experienced? Just about every person developing
new habits will suffer a lapse at some point and believe it or not, lapses can actually be
constructive. When you experience one, stop and think about what happened. Why did it
happen and what can you learn from it? What can you do differently in the future? Most
importantly, think about why you are successful when lapse(s) do not occur.

• How can I take my new behaviors to the next level? Now that you’ve dipped a toe in the
water, shove your entire foot in there. What is the next step you need to take? Do you want
to exercise more intensely, cut back on artificial sweeteners, eat more vegetables, or even
just sit less often? Write down three ways to progress your eating and exercising habits.
Then choose one idea from each list and make it happen.

5. I Made Changes Months Ago and Am Planning to Continue

Congratulations. You made changes months ago and they are still going strong. You are
consistent, although a lapse may happen on occasion. At this point, you may be looking for
more motivation, research-backed ways to make more changes to your lifestyle, or just ways to
improve the changes you’ve already made. In that case, you’re ready to:

• Share the good news. You’ve been maintaining great habits and now it’s time to talk about
it. Tell at least three people about your changes. Let them know how different you feel, what
new behaviors you’ve adopted, and how you plan to execute this new behavior in the future
(maintaining or progressing at the current level).

• Write down any lessons learned from lapses. Remember, lapses are normal and
completely expected. The question is what did you learn? How did you work around it?
What motivated you to get back on track?

• Reach for new habits, new goals. If you have achieved your original goals, then it’s time
to set new ones. Why not get your blood glucose even lower, lose more weight, or gain
more strength? Target your behavioral goals, such as taking walks at least two times per
week. If you are already walking twice per week, aim for a minimum of three. For more
ideas on behavioral goals, read Chapters 5 through 9.

The more lifestyle adjustments you adopt, the better you become.
A Key Concept in The Heart Healthy Lifestyle
In the first chapter, I described The Heart Healthy Lifestyle: The Prevention and Treatment of
Type 2 Diabetes as a buffet of choices. In other words, grab a plate and fill it with whatever
seems most appealing to you. The more lifestyle adjustments you adopt, the better you
become. However, the lifestyle habits advocated in this book are not “all-in or not at all”
concepts. If you are the type of person who is much more comfortable playing it safe at the
beginning of anything new, then I’m here to help you. Even if you are still not sure how these
recommendations fit into your life, I have devised a Key Components structure for the remainder
of the chapters to make it easier.

What’s Minimal?
My friend Julio works out five times per week, with each workout lasting an hour. His health is
extremely important to him and he values his workouts. Because of this, Julio believes that
working out every day is critical to maximizing his health benefits.

The downside of Julio’s routine is that he feels awful emotionally when he misses even a day at
the gym. He’s devastated after missing two or three days in a week. To be honest, I’m not
surprised that he feels down in those situations: to him, attending the gym only two or three
times in a week means he’s failed.

What if working out twice per week were enough to keep Julio healthy? With this in mind, he
couldn’t be a failure for working out two or three days because he would reach or exceed his
goal each week. Also, what if working out for a half hour were enough to make dramatic health
improvements? He could attend the gym on days when an hour of free time just wasn’t possible.

The fact is that working out as often as Julio has demanded of himself is just not necessary.

Challenge 4: Activate Your Support Team

Make contact with the family, friends, and/or coworkers who you identified as your support team
in Chapter 2. This initial contact is a way for you to mention the changes you are making and to
share the goals you’ve chosen. Select one of the options below if you’re not sure how to initiate
the conversation:

• I’m tired of relying on medications to manage my diabetes, so I’m going to start improving
my _______ (sedentary habits, eating habits, etc.).

• I feel as if exercising could help my diabetes, so I’m going to start working out at the gym,
walking, etc.
 • I have been reading The Heart Healthy Lifestyle and it provides ideas on how to change my
lifestyle to help my diabetes. I’m going to start implementing some of the recommendations
in the book.

• I don’t want diabetes, so I’m going to start making some specific changes to my lifestyle
that research shows to be effective.

Mentioning your lifestyle changes can be an offhand comment, text, or email. Simply mentioning
it accomplishes the task. However, if you’d like to take it a step further, ask the person to check
in with you periodically to see how your changes are going. Ask them to brainstorm ideas when
bumps in the road occur.

This brings us to the “What’s Minimal?” section, which provides an easy way to get involved in
an activity with minimal effort or time. “What’s Minimal?” includes the smallest amount research
has shown to work or, where research isn’t available, my suggestion for getting started in an
activity at a basic level.

If you are like Julio and become limited due to life’s demands on your time, you can still keep
positive momentum and your new habits. In addition, starting “What’s Minimal?” means you can
then increase your commitment as you become more comfortable and ready.

If your significant other, friends, family, or coworkers decide to engage in The Heart Healthy
Lifestyle with you, even better. As Aesop said, “In union, there is strength.” And this support
provides an opportunity for another great accountability tool.

Challenge 5: The Daily Success Contract

All great accomplishments are products of great teamwork. Michael Jordan was the leader of six
NBA championship-winning teams and is largely considered the best basketball player of all
time. But Jordan was just part of a 12-man team and had four other players on the court with
him at all times. His teammates and head coach were also successful, making All-Star teams
and earning entry into the Basketball Hall of Fame. Jordan and his teammates also enjoyed the
benefit of having several coaches who supported the players and taught them skills needed for
success.

So now it’s time to pick your championship team and work together on the common goal of
treating or preventing diabetes. The Daily Success Contract is a pact between you and others
who are trying to prevent or treat diabetes to contact each other every day to make sure you are
doing at least one constructive activity per day. In essence, you are now each other’s coaches,
teammates, and cheering squad. The pact can consist of just two people or a maximum of
however many you want.

Every day, contact each member of the pact by dropping by his/her office, sending an email,
texting, making a phone call, contacting via an online forum, etc. Contact doesn’t need to be the
same each day, as long as there is contact. Ask the person what he or she has done or plans to
do during the rest of the day that fights diabetes. Examples include going for a walk, strength
training, and just substituting vegetables in place of pasta at dinner.

The contract features a general statement indicating that you are responsible for speaking with
every other person on the contract each day to ensure that the individual has or will take a
specific anti-diabetes action. Keep in mind that the contact doesn’t have to be substantial: a
group email or a text message will suffice. If all members work together, place the contract at a
location where each person can see it every day. Otherwise, have each member print the
contract and post it in a key location where it will be seen every day.

You can copy the daily success contract example below or create your own. If everyone in the
group agrees that daily communication is too difficult, then alter the contract to indicate how
often everyone is to stay in contact, whether that’s daily, odd-numbered days, weekly, etc. Just
make sure that there is a standard for contact. Communication is all what it’s about, right?
 Chapter 5: Strength Training

Your body has four options for excess glucose in your blood: use it as fuel, store it as glycogen,
store it as fat, or leave it in your blood. A lack of muscle to use glucose for fuel or glycogen is a
cause of high blood glucose. This chapter will show you how just a few minutes of strength
training per week will control your blood sugar and prevent fat storage.

Glycogen: The Desirable Glucose Storage

As mentioned in Chapter 2, glucose is stored as glycogen in the liver and muscles. The muscles
are, by far, the largest glycogen storage, having a capacity to hold roughly three times the
amount of glycogen that the liver can.

It’s no secret that, as we age, we lose muscle mass. With age-related muscle loss, our capacity
for storing glucose decreases. For example, one study published in Diabetes Care looked at
individuals between 60 and 70 years old and found that four months of inactivity led to a 23%
decrease in muscle glycogen storage [7].

However, glucose doesn’t just disappear if muscles can’t store them. If it isn’t immediately used
for energy, unstored glucose remains in the blood or is stored as fat. As muscle mass continues
to shrink, we are likely to see our blood glucose rise and our body fat increase.

Having a Say in Your Fate (and Your Muscles)

The good news is that you have a voice and can be proactive with your health. You don’t have
to just sit back and watch your muscle mass shrink while your blood glucose and body fat
increase. Strength training will increase muscle size and the capacity to store glucose. The
same four-month study that showed a 23% glycogen storage decrease in inactive 60- to 70-
year-olds also showed promising news. As seen in the graph below, diabetics of the same age
group gained muscle mass and increased muscle glycogen storage by 31% [7]. Essentially,
they were able to store an additional one-third of glycogen after just four months of training.
Another underlying mechanism for the effectiveness of strength training is the muscle fiber
involvement. Fast-twitch muscle fibers are larger fibers used for activities requiring a high-
intensity effort over a short period of time. Fast-twitch muscle fibers use glucose for energy.
Strength training utilizes the fast-twitch muscle fibers, unlike most aerobic exercise and daily
activities.

Additional benefits of strength training include:

• Decreased fasting blood glucose [6,7,26].

• Improved HbA1c. Some studies have shown absolute improvements of 1% or greater

[6,7,13]. How significant of a change is 1%? Every .3% reduction in HbA1c equals a 6%
reduced chance of early mortality [23].

• Increased insulin sensitivity [1,6]. As you may recall from Chapter 2, insulin sensitivity is the
ability of cells to respond to insulin and allow glucose into the cells. If you participate in
strength training, you will improve the process of removing glucose from your blood. A
single strength-training workout can improve your insulin sensitivity for 96 hours [22].

• Blood insulin levels decrease as well [3], which is another sign that the glucose use and
storage process is working more effectively and efficiently. High levels of circulating insulin
are a sign of diabetes and lead to fat storage.

• All of the previously stated benefits work synergistically to help diabetics become less
reliant on medications. As shown in the graph below, the four-month study that looked at
glycogen storage differences in 60- to 70-year-old diabetics also detailed medication
changes. Seventy-two percent of the strength-trained type 2 diabetics reduced or
eliminated their medications [7]. This is compared to a medication reduction in only 3% of
 type 2 diabetics who did not exercise or change their lifestyles. On the other hand, 42% of
those sedentary diabetics actually increased their medications.

Besides the diabetic benefits, strength training also helps diabetics increase muscle size,
strength, and lose fat, including inner abdominal fat [6,25].

As you can see, strength training helps diabetics store more glucose as glycogen, use more
glucose, and transfer glucose out of the blood in a more efficient manner. Ultimately, all of these
effects result in a decreased reliance on Insulin, Metformin, Sulfonylureas, and other diabetes
medications. For this reason, strength training is a natural fit for type 2 diabetics.

Tammy’s Story
Diabetes is commonly found in people who are obese. However, as Tammy can tell you, lean
people don’t get away that easily.

“How could I have a high hemoglobin A1c? I weigh less than 100 lbs,” Tammy asked as her
doctor read the results of her blood test. Her hemoglobin A1c was 5.9, which falls in the
prediabetic range.

“I was in shock because I didn’t think that I fit the ‘mold’ of what a prediabetic was. The world
doesn’t embrace this. And being prediabetic…I was a minute away from full diabetes. The
diagnosis scared me tremendously.”

Tammy started testing her blood glucose about three times per day. Her post-meal glucose
often reached 180 mg/dl, also considered to be in the prediabetic range.
Choosing strength training was the natural choice for making a change. In addition to her high
blood glucose, Tammy dealt with various joint pains that could also benefit by strength training.
She knew exercise would help her mentally and physically.

Tammy used a full-body strength training routine that lasted about 20 minutes, as well as dietary
changes (see Chapter 8). She worked out two to three times each week and within a month her
blood glucose measures improved. Not only did she notice the improved shape of her muscles,
but also many of her friends and family commented on how great she looked only three months
into training.

Within her first six months, Tammy’s HbA1c and post-meal glucose dropped to healthy, non-
diabetic ranges. She continues to strength train two or three times per week. In addition to her
happiness with appearance and health improvements, Tammy maintains her strength training
routine because it’s convenient.

“I never get tired of going to the gym because I can do just 20 minutes of strength training in my
regular routine easily,” she said.

Adding strength training to basic dietary changes resulted in a change of blood glucose and
appearance for Tammy. Now that you know the benefits of strength training from research and
via a personal testimony, let’s discuss incorporating strength training into your life.

Strength Training Basics

Using my positive experiences from more than 9,000 sessions in my personal-training practice, I
have created a strength-training program that produces successful health benefits. This
program is simple and straightforward, as follows:

1. Map out a training schedule that works for you:

a. Train your full body: legs, thighs, upper torso, and midsection during the course of your
usual routine.

b. Train all muscles into one day or split your body into a two-day routine of 1) legs and
midsection, and 2) upper body.

2. Perform 1 to 3 sets per exercise.

3. Lift the weight in about 3 seconds, and lower the weight in about 5 seconds, totaling roughly
an 8-second repetition.

4. Assess your weights on a 1-10 scale, with 1 being, “I can do this all day,” and 10 being, “This
is freakin’ impossible.” The weights during your first workout should feel like a 5 or 6 at the
start of each set. Ultimately, you want to attain a starting difficulty of 7 to 8 with each exercise.
Every exercise should end in a 10 (see #5).
5. Starting around your third week, you should perform each set to complete exhaustion. This
means that your last attempt to lift the weight produces no movement or a partial repetition
despite 100% effort.

6. When you’ve reached 12 reps pretty easily, increase the weight about 5%. If you cannot
accomplish 4 reps before complete exhaustion, consider decreasing the weight 5% for the
next workout.

7. Breathe through your mouth constantly during each exercise. Breathing through the mouth
enables greater oxygen intake and carbon dioxide release than breathing through the nose.
This instruction is especially important during the last few repetitions of a set, when the
intensity is at its peak and temptation to hold your breath increases.

8. Keep your neck relaxed and look forward throughout each exercise.

9. Train all muscle groups one to three times per week on nonconsecutive days. I recommend
setting a goal of two or three times per week, which is what I use with most of my clients.

What’s Minimal?
Although I recommended one to three sets per exercise, that may seem vague to you. Why do
three when you can just do one? They are all effective for improving blood glucose, but each set
requires a different set of circumstances to be effective. Pick what you feel is most sustainable.
You also have the option to vary the sets from week-to-week or workout-to-workout.

When it comes to the quantity of exercises, research shows that HbA1c, insulin sensitivity, and
morning blood glucose measures can be improved using just five exercises [6]. If you feel that
learning too many exercises at the start will be overwhelming, then just learn five that work the
major muscle groups. We’ll discuss specifics shortly.

If you decide to commit to five exercises, then research indicates that three sets per exercise
will do the trick [6]. I train Ron, a diabetic man, who performs one set of five exercises, three
times per week (each workout requires about 10-15 minutes). While Ron has made no other
changes in his lifestyle and still eats dessert a few times per week (due to his personal
preference), performing that small amount of strength training has helped his HbA1c decrease
from 6.4% to 6.1%. This result is especially impressive when considering that his HbA1c was
rising for years prior to strength training.

Ron’s blood glucose could improve greatly if he was to add Pro LiVe Meals, Active Sedentary
Time, or some of the other recommendations you will find in this book. However, the single-set
approach with only five exercises has not been tested in research. What that means is there is
no proof that it is generally effective in lowering blood glucose with no other lifestyle changes.
If you decide on five exercises and three sets per exercise, then choose exercises targeting
major muscle groups. Start slowly and aim for one set per exercise. After two weeks, add an
additional set to prevent experiencing major soreness. After two weeks with two sets per
exercise, you’re ready to add a third set.

The following are examples of full-body routines made up of five exercises.

1. Full Body with Lower-body Emphasis Routine: Leg Press, Leg Curl, Leg Extension,
Pulldown, and Chest Press.

2. Full Body with Upper-body Emphasis Routine: Leg Press, Pulldown, Chest Press, Row,
and Shoulder Press.

If you would rather plan a split routine where upper and lower body exercises are split into
multiple days, follow one of these two workouts:

3. Split Routine:

Day 1: Leg Press, Leg Curl, Hip Adduction, Hip Abduction, and Ab Crunches

Day 2: Pulldown, Chest Fly, Row, Lateral Raise, and Triceps Extensions

When One Set is Enough

When it comes to strength training, I prefer to do one set per exercise in order to perform more
total exercises. But can one set per exercise improve your blood glucose? Yes, but there is a
catch.

A study published in The Journal of The American Medical Association used a single-set
strength-training routine with type 2 diabetics [10]. The trainees were an average of 56 years old
and started with an average HbA1c of 7.7%. They exercised for nine months with a strength-
training routine twice per week. These workouts included nine exercises in each workout that
implemented all major upper- and lower-body muscles.

At the end of the study, the trainees experienced a range of HbA1c decreases from .3% to
1.0%. Forty-one percent of the group experienced a decrease of .5% or were able to decrease
their medications. The strength-training program required only 30 to 40 minutes per week.

The results sound great, right? But there is a catch. An aerobic exercise program accompanied
the strength-training program. In addition to the single-set strength training, the trainees
performed around 100 minutes on the treadmill per week (at an effort similar to a brisk walk for
most people).

If you choose to use one set, which I use when training others and myself, consider
adding a few walks, hikes, or some cycling each week.
These results do not mean that single-set strength training is ineffective for improving your
blood glucose on the whole. It just happens to be the only study I have seen which shows a
benefit using just one set. If you choose to use one set (which I use when training others and
myself), consider adding a few walks, hikes, or some cycling each week.

Our case study from Chapter 1, Mark, uses a full-body, strength-training routine that features
one set per exercise. He strength trains twice per week for a total of 15 to 18 minutes per
workout. Strength training is the only mode of exercise that he performs and his HbA1c has
changed from 7.2% to 5.2%. However, Mark has also addressed other lifestyle factors, such as
Active Sedentary Time and Pro LiVe Meals, which we discuss in Chapters 7 and 8.

However you decide to work out, remember to make small adjustments to your routine over time
to sustain your interest. Start with a full-body workout then switch to a split routine, or start with
two days and then switch to three days per week. Or for a change, start using the chest press to
build strength in your chest and shoulders and then switch to the chest fly, or switch from the
shoulder press to lateral raises. As long as you are working hard (till complete exhaustion on
each exercise, remember?) and are training regularly, altering some of the structure should not
negatively affect your results.

The results come quick if you just show up and do it.

Longer Routines
The routines discussed up to this point address the minimal amount of exercises needed to
produce major changes in blood glucose levels, insulin function, glucose storage ability, and
muscular strength and size. But if you’re looking to perform longer routines and address smaller
muscle groups, consider following one of the examples below:

1. Full Body 1: Leg Press, Leg Curl, Hip Abduction, Hip Adduction, Pulldown, Chest Press,
Row, Shoulder Press, Biceps Curl, Triceps Extension, and Ab Crunch.

2. Full Body 2: Pulldown, Chest Fly, Reverse Fly, Lateral Raise, Biceps Curl, Triceps
Extension, Leg Press, Leg Curl, and Ab Crunch.

Mark credited the start of his strength-training program as the tipping point where his physique
and fitness gains started happening quickly. However, he didn’t embrace strength training
immediately. During his first workout, he felt his heart beat faster as his muscles worked hard to
lift the weights (an expected and positive physiological effect of strength training), and became
worried that this was a negative sign for his health. After he was reassured that this was a
normal and desired reaction, Mark went on to finish his first workout.

“Somehow I had developed this fear that if your heart started beating faster and if you started
breathing heavier, then you were negatively stressing your body,” Mark said. “The monster in
the closet? That was mine. The approach that was taken was to ease myself into it. The results
come quick if you just show up and do it.”

Unlike alternative methods like medication, strength training creates permanent changes to your
body structure. These changes then aid your body’s ability to use extra glucose. In other words,
strength training makes long-term changes that favor healthy blood glucose levels. Considering
that it requires minimal time when compared to many exercise routines AND it can improve the
way your body looks and functions, it is definitely worth the effort.

Strength-Training Exercises
The following are instructions and pictures of the exercises suggested above. Remember that
the intensity of the exercise, not the equipment used, is key in attaining the desired benefit.

Leg Press

Target Muscles: Gluteus maximus, quadriceps, and hamstrings (butt and thighs)

1. Position the seat so your thighs are almost completely perpendicular to the ceiling (or as
close to this position as you can achieve).

2. Push through your heels until the knees are slightly bent (straightening the knees
completely allows the muscles some rest, which lowers the exercise intensity).

3. Continue to press through your heels as the footplate comes back to you in about five
seconds.

4. Briefly tap the lifted weight to the weight stack without any rest or pause between reps.
Leg Curl

Target Muscles: Hamstrings and gastrocnemius (back of the thighs and calves)

1. Align the axis of rotation with the middle of your knee and the heel pad about two inches
above your heel.

2. Flex your ankles, bringing the top of your feet toward your shins.

3. Pull your heels as close to your butt as possible and then “squeeze” for two seconds.

4. Resist the weight as your legs straighten.

5. Once your legs are straight, slowly but immediately begin the next repetition.

Leg Extension

Target Muscle: Quadriceps (front of the thighs)

 1. Align the axis of rotation with the middle of your knee. Place the shin pad about 1 to 2
inches above the tongue of your shoes.

2. Push the shin pads up until your legs are completely straight.

3. Pull up on the handles as your legs straighten (allowing your butt to stay in the seat).

4. Lower the weight in roughly five seconds and until your knees reach a 90-degree angle.
Start the next repetition slowly but immediately.

Hip Abduction (often referred to as the “outer-thigh” exercise)

Target Muscles: Gluteus medius, gluteus minimus, and piriformis (butt and deep hip)

1. Align the axis of rotation with your hip socket.

2. Push the pads as far apart as possible, with the thighs primarily pressing against the pads.

3. “Squeeze” for two seconds.

4. After slowly lowering the weight, briefly tap the weight stack before starting the next
repetition.
Hip Adduction (often referred to as the “inner-thigh” exercise)

Target Muscles: Adductors (inner thighs)

1. Align the axis of rotation with your hip socket.

2. Press the upper thighs against the pads until the pads meet.

3. “Squeeze” for two seconds.

4. After slowly lowering the weight, briefly tap the weight stack before starting the next
repetition.

Ab Crunch

Target Muscle: Rectus abdominus (front of the midsection)

1. Lie on the floor with the knees bent and feet on the floor with heels about 12 inches from
your butt.

2. Curl your upper torso, bringing your chest toward your thighs.
 3. Slowly lower your upper back until your head taps the ground. Then slowly and
immediately start the next rep.

4. Keep your neck straight, maintaining the same distance from the chin to the chest
throughout the entire repetition.

5. To increase the resistance, hold a dumbbell or weight plate over your head and out of
sight while performing repetitions.

Pulldown

Target Muscles: Latissimus dorsi, trapezius, posterior deltoids, and biceps brachii (upper/mid
back, shoulders, and upper arms)

1. Raise the seat until your thighs are snug against the thigh pads.

2. Grab the bar with an underhanded grip, positioning your hands slightly wider than your
shoulders.

3. Pull your shoulder blades down, and then pull your elbows down until they are on the
sides of your ribs.

4. As you slowly let the bar rise, unshrug your shoulders.

5. As soon as your arms are straight, slowly and immediately start the next rep.
Row

Target Muscles: Trapezius, rhomboids, posterior deltoids, and biceps brachii (upper/mid back,
shoulders, and upper arms)

1. Position the chest pad and seat to allow your arms to completely straighten when grabbing
the handles and have your hands slightly lower than the shoulders.

2. Bring your feet back to prevent your legs from helping in the exercise.

3. Retract your shoulder blades, then pull the elbows as far back as possible.

4. As you start to lower the weight, unshrug your shoulders.

5. Briefly straighten your arms before starting the next repetition.

Chest Press

Target Muscles: Pectoralis major, anterior deltoids, and triceps brachii (chest, shoulders, and
upper arms)

1. Align the seat to position the height of the handles around the mid or lower chest. Keep
the elbows at the same height of the hands.

2. Maintain a slight arch in the lower back, keeping the chest up and proud.

3. Push through the heels of your hands until your elbows are slightly bent (completely
straightening the elbows allows the arms some rest, which you don’t want).

4. Slowly bring the elbows as far back as comfortable. Avoid bringing the elbows far behind
your shoulders as this may overstretch the shoulder capsule.
Chest Fly

Target Muscles: Pectoralis major and anterior deltoids (chest and shoulders)

1. Align the back of the seat to match the axis of rotation with your shoulder joint. Move the
seat to a position where your elbows are slightly below the shoulders.

2. Maintain a slight arch in the lower back, keeping the chest up and proud.

3. Push through your elbows and arms until the pads meet, then “squeeze” for two seconds.
Your hands should be relaxed throughout the movement.

4. Slowly bring the pads as far apart as comfortable. Avoid bringing the elbows far behind the
shoulders as this may overstretch the shoulder capsule.
Shoulder Press

Target muscles: Deltoids and triceps (shoulders and upper arms)

1. Position a free-weight bench at roughly a 120-degree angle. Lean back with your chest up
and lower back slightly arched.

2. Start with your palms facing each other and elbows by your sides.

3. Push the weights straight up until your elbows are slightly bent and palms are still facing
each other.

4. Slowly lower the weights back to the starting position. As soon as you reach the start,
immediately and slowly start the next rep.

Lateral Raise
Target Muscles: Deltoids and biceps brachii (shoulders and upper arms)

1. Stand erect with your palms facing forward and feet about hip-width apart.

2. While keeping the elbows straight, raise the weights until your arms are parallel to the
ground.

3. Slowly lower your arms until the weights tap the sides of your thighs. Then immediately
start the next repetition without rest.

Biceps Curls

Target Muscle: Biceps brachii (upper arms)

1. Sit on a bench that is positioned at or close to a 90-degree angle.

2. Slump over, taking your shoulder blades away from the bench while keeping your lower
back pressed against the bench.

3. With the palms facing away, bring the wrists as close to the shoulders as possible.

4. Slowly lower the weights until your arms are completely straight, then immediately begin
the next rep.
Triceps Extension

Target Muscle: Triceps brachii (upper arms)

1. Stand with a split stance, leaving one foot in front of the other.

2. Pin your elbows to the sides of your ribs and below your shoulders. Maintain this position
throughout the exercise.

3. Grab the bottom of the rope and push down and apart until your elbows are completely
straight.

4. Slowly allow the rope to rise until your hands are close to your chest. Immediately start the
next rep.

As previously mentioned, you are not limited to the exercises above. Use what is available to
you. They key is doing all that you can do. In other words, perform each exercise till fatigue
(starting in your third week of exercise). Train all of your major muscles regularly, including your
thighs, hips, midsection, and upper body. Like Tammy and Mark, you can see your blood
glucose improve in less than a month with strength training, and the bonus is that your body will
change shape as well.
 Chapter 6: Aerobic Exercise

Remember the old saying, “Reading is Fundamental?” Well, when it comes to your health,
“Walking is Fundamental.” Quite simply, walking makes it possible for us to accomplish simple
tasks of transportation around our homes, our jobs, and our neighborhoods. And even more
important, walking is an effective way for diabetics to exercise. In order to understand why, you
have to understand the process of glucose entering your cells.

Insulin Sensitivity: A Matter of Getting Glucose Into the Cell

As mentioned in Chapter 5, when blood sugar rises, your body has four uses for the excess:
use it as fuel, store it as glycogen (in the muscles or liver), store it as fat, or leave it in your
blood. The desirable options, fuel use and glycogen storage, take place inside cells. Getting
glucose into those cells, however, isn’t a given.

Glucose enters cells through the special glucose doors. For most tissues, including our
muscles, insulin is the key that unlocks these doors, allowing glucose to enter.

However, during a state of insulin resistance, the cells’ glucose doors are largely resistant to
insulin’s attempts to open them. In muscles, insulin resistance occurs for a number of reasons,
including having full glycogen stores or having no need for more fuel because the muscles are
inactive.

As a result of insulin resistance, glucose is stored as fat or left in the blood. Remaining in the
blood is especially damaging for two reasons. First, having high blood sugar causes tissue
damage and can eventually lead to vision loss, amputations, and many of the other harsh side
effects that were discussed in Chapter 2. Second, the Beta cells of the pancreas respond to
insulin resistance by producing more insulin. Over time, Beta cells can die from being
overworked, and then your ability to produce insulin and control blood sugar both digress.
Essentially, that’s how diabetes is developed.

The condition opposite to insulin resistance is insulin sensitivity. In this state, the cells’ glucose
doors are sensitive to insulin’s attempt to open them. A normal or below-normal amount of
insulin is needed to help excess blood sugar get into cells. Not only does this save the Beta
cells from overworking, but the excess blood sugar is also likely going to be used for glycogen
storage or immediate energy use.

Just one week of exercise creates a significant change in insulin sensitivity.

Now, how do we attain and improve insulin sensitivity? This is where aerobic exercise, such as
walking, is key for diabetics. Aerobic exercise increases insulin sensitivity in diabetics and
healthy individuals [17, 30]. In fact, just one week of exercise creates a significant change in
insulin sensitivity [30].

According to a study in the Journal of Applied Physiology, healthy adults as old as 87 can
improve their efficiency in using or storing glucose as glycogen by about one-third just by
exercising [17]. The men and women in the study averaged 2.5 workouts per week over a span
of 10 to 12 months. Each workout featured a mix of walking and cycling. Besides the benefit of
increased insulin sensitivity, the exercise also decreased the amount of insulin in the
participants’ blood, which is a sign of decreased stress on the Beta cells and also allows for
weight loss to occur.

The American Journal of Physiology: Endocrinology and Metabolism also published a study
based on a cycling and walking program with diabetics who averaged 64 years old [30]. After
just seven days of exercise, one hour per day, the participants’ blood glucose, blood insulin, and
insulin sensitivity all improved.

For diabetics, the duration of aerobic exercise is more important than the intensity.

Following the studies listed above, it becomes obvious that aerobic training can improve the
process of getting glucose out of your blood and into your liver and muscle cells to be used as
fuel. And allow me to let you in on another important finding: for diabetics, the duration of
aerobic exercise is more important than the intensity in a number of ways.

What this means is that in the old tale of the tortoise and the hare, the tortoise had the right idea
in many ways. In several studies, the groups performing the most aerobic exercise were the
most successful in improving insulin sensitivity [25,48]. Therefore, you do not have to perform
cardio exercise in an intense, sprint-like fashion. While that intensity will help you in some
measures of health, it is not required for this process. Improving your insulin sensitivity can be
accomplished effectively by increasing your total time, regardless of your aerobic exercise
intensity. You can see the results from one study in the graph below [48].
The results above come from the STRRIDE Trial, a large study examining the role of aerobic
exercise on heart disease risk factors in adults. The participants were overweight or obese,
sedentary, had high or borderline high triglycerides, and were 40 to 65 years old.

Despite a greater intensity and about five more miles traveled, the 172-minute-per-week jogging
group benefited less than the group that walked 176 minutes per week.

Aerobic exercise also benefits the Beta cells. As mentioned earlier, Beta cells in the pancreas
are responsible for producing insulin. For people with insulin resistance (on their way to
diabetes), Beta cells have to work much harder to produce extra insulin to remove the
necessary amount of glucose from the blood. When this occurs over the long term, Beta cells
“burn out,” stop producing insulin, and die. It is the “burn out” of Beta cells that leads to diabetes
and eventually leads to taking insulin injections (See Chapter 2).

According to the STRRIDE trial, aerobic training increases Beta cell function for prediabetics
and diabetics [48]. In this study, the participants performed each of the exercise protocols for
eight months. All three protocols improved the ability of Beta cells to make up for insulin
resistance by creating enough insulin.

The key take-home point is that the intensity of the workout is not as important as the longevity,
and this study proved that the group performing the lowest intensity with the greatest total time
was the most effective in increasing Beta cell function and insulin sensitivity.
What’s Minimal?
Multiple studies illustrate that insulin sensitivity and total blood insulin changes from aerobic
training last for about 72 hours [5,30]. This means that aerobic training gives you insulin benefits
at a minimum frequency of once every third day.

Even if you think this is not possible, you need to start somewhere.

The minimal total weekly time you need to exercise to make an improvement is 113 minutes per
week, according to the studies I have compiled regarding aerobic training and insulin sensitivity.
This boils down to 16 minutes per day, seven days per week, or about 23 minutes per day over
a five-day period. Even if you think this is not possible, you need to start somewhere. Try a 10-
minute walk a day or two per week (during a break at work, first thing in the morning, with a
friend on the weekends, etc.). Once you have managed that, consider increasing the amount of
days or the duration of each walk.

In order to treat or prevent diabetes, you must make the total time that you perform aerobic
exercise a focal point. The total weekly time you exercise is more important than the intensity or
mode that you choose. In other words, 20 minutes of walking or light cycling is likely going to
increase your insulin sensitivity, total blood insulin, and Beta cell function more than if you
choose to jog for 10 to 15 minutes.

Bonus Points: Combining Strength Training and Aerobic Exercise

Like I said earlier, The Heart Healthy Lifestyle is a buffet of options for changing your lifestyle; it
is not a prescribed plan. Choose what looks most appealing to you and decide if you want to
implement one suggestion or try them all. Obviously, the more suggestions you adopt into your
lifestyle, the greater your benefit.

While choosing your exercise plan, you may decide to implement both strength training and
aerobic exercise. If that’s the case, I wholeheartedly support the decision. But do the two
somehow nullify the individual benefits of each, or do they increase the combined changes?

Researchers at the University of Ottawa conducted a six-month study with 251 type 2 diabetics
to answer this question [47]. Men and women, who ranged from 39 to 70 years old, were split
into one of four routines: strength training, aerobic training, both, or nothing.

The strength training and aerobic routines were both performed three days per week. The
combined-training group performed the full strength training and aerobic routines, giving them
an inherent advantage in terms of total exercise time. However, the important question is
whether the two training programs complemented each other or weakened the individual effects
of each program?

The answer is in the numbers since the combined-training group experienced an HbA1c change
that was greater than the total changes of the individual strength-training and aerobic-exercise
groups. Keeping in mind that a .3% decrease in HbA1c is equivalent to a 6% reduction of risk of
premature death [23], the .9% drop experienced by the combined-training group equates to an
18% decreased risk of early death.

As a bonus, the combined-training group also experienced major improvements in waist

circumference, body fat, visceral fat (the fat surrounding your organs), triglycerides, and high-
density lipoproteins (HDLs).

So now that you know all of this, you may be wondering which mode or modes are most
effective in your limited time frame. Based on the information above as well as a study in The
Journal of the American Medical Association (JAMA), the answer is a combination.

The JAMA study placed type 2 diabetics into a combined exercise program versus individual
aerobic and strength-training programs, matching each regimen for equal weekly exercise time
[10]. The combined group was the most successful in decreasing overall HbA1c and medication
dosages.

Your glycemic control, insulin sensitivity, overall health, and lifespan will improve with the
adoption of strength training and/or aerobic exercise. However, if you choose to combine them,
for example adding two short strength-training workouts to a few walks or bicycle rides per
week, then your health, physique, and lifespan will benefit even more. Whatever you choose,
the future of your health will look much brighter.
 Chapter 7: Active Sedentary Time

Did your mother ever tell you to stop watching TV and go outside to play? Well, it wasn’t just
watching too much television that was detrimental to your health. All that time sitting in a
stationary position wasn’t doing you any good either. Remember Mark, from Chapter 1? He
figured this out the hard way.

“I was more sedentary than a couch potato,” Mark said. “I went to work, sat behind a desk, went
home, sacked out on the couch, then dragged myself to sleep.” That was how Mark described
his lifestyle prior to making the effort to change. I asked him if he got up periodically. “Not if I
could get someone else to bring me food and beer from the refrigerator,” he replied.

Sitting time should not be confused with a shortage of physical activity or exercise. Total sitting
time is an issue of too much inactivity.

In the past few decades, researchers have looked at the effects of total sitting time and it
doesn’t look good. Most total-sedentary-time research looks at associations between health
effects and sitting quantity. While these studies don’t show causation, they do have reason to
grab the attention of a type 2 diabetic. (Of course, studies that could prove causation between
sedentary time and negative health outcomes are considered unethical since it would require
the participants to partake in behaviors detrimental to their health).

In a study published in The New England Journal of Medicine, researchers observed

associations between various lifestyle habits and weight changes over a four-year period in
nearly 120,000 people [38]. These researchers calculated that each daily hour of television time
equates to one-third of a pound gained every four years. In other words, if you watched three
hours per day, you could gain a pound every four years. If you’re like many people and watch
about six hours per day, then you could pack on two pounds every four years. This may not
sound like much, but over time, the pounds add up. Of course, just watching television won’t
make you fat, but the time you sit while watching plays a significant role in that equation.

Total sitting time can be linked to a higher prevalence of insulin resistance [49]. Sitting very
often creates an “inactive physiology,” where our muscles work less and our body, in some
ways, shuts off [41]. So in effect, our muscles are resisting the glucose because the muscles
don’t need it. They aren’t really using any energy (glucose), so why take in more?

Rest at night is healthy, but too much rest can be harmful, especially during your
conscious hours.
In Mark’s case, prior to his lifestyle changes, he logged roughly 16 hours of sitting at a desk and
lounging on the couch each day. Using the above equation, that means he was packing on just
over 5 pounds every four years, not including the effects of what he was eating while sitting on
that couch.

During the day, you must create at least a small periodic demand on your muscles and
metabolism. Rest at night is healthy, but too much rest can be harmful, especially during your
conscious hours. When you sit for hours, you are creating inactive muscles, which in turn
decreases the uptake of glucose from the blood into the muscles and liver.

What’s Minimal?
I know what you’re thinking right now. “I work all day at a desk. How am I supposed to avoid
sitting?” I understand that can be difficult, but there is a practical solution: break up your periods
of sitting more often with a little physical activity. In other words, occasional movement lessens
the damage of sitting.

It pays to break up your long-term sitting marathons. According to a study in Diabetes Care that
monitored sedentary people, those who interrupted their periods of inactivity the most were
significantly more successful in removing glucose from their blood than those who were
consistently sedentary [24].

It pays to break up your long-term sitting marathons.

Of course, I understand that you can’t get up and walk a mile or sprint through the halls while at
work. However, the movement intensity needed to achieve a non-sedentary state could be a
very brief walk, a few jumping jacks, or even marching in place while you’re on the phone.
Essentially, whether you have diabetes or not, a good way to improve your blood glucose use
and storage is to break up your long sitting periods with some kind of movement. Even standing
is an improvement, since it requires the muscles of the legs and hips to work.

Here’s my minimal recommendation: get up every hour. The table below presents ideas to
break up your sedentary periods, and for decreasing overall sedentary time.
Play Active Sedentary Time Tag and make a game out of your sedentary interruptions and get
coworkers involved. Designate an object—a stuffed animal, a tape dispenser, a funny picture,
etc.—as the tag item. Each person who has the item must keep it for one hour, then get up and
put it on someone else’s desk silently and walk away. (Choose a length of time that works best
for those in the game.)

A Walking Workstation

How often you get up to move around depends on your situation, but start with an hour as the
minimal frequency. Greater frequencies will provide better results, so if it’s possible for you to
get up every 20 minutes, even better. Set an alarm on your phone as a reminder. (Trying to
stick to a routine of breaking sitting periods without an alarm often leads to forgetfulness).
However, if you work best without a routine, by all means, do what works best for you.
Just remember that the idea is to stand up and move around as often as you can during sitting
periods. The greater the intensity, frequency, and duration of the movement period, the better
the benefit (glucose removal from the blood) will likely be.
 Chapter 8: Pro LiVe Meals

If you walked into your bathroom and saw the bathtub overflowing with the water still running,
what would you do? Would you start bailing the water out of the tub, or head to the root of the
problem and turn off the water at its source? Only one answer can help to fix the situation
before it gets worse.

The same is true with glucose. In the case of type 2 diabetics, the overflowing tub represents
the cells that use glucose for glycogen or fuel. The water spilling onto the floor represents the
excess glucose that remains in your blood. Although most of the glucose (water) that enters
your blood should find its way to your cells (tub), the influx of glucose (water) is so great that the
desired holding place is at maximum capacity. That’s where the overflow comes in to play.

So what’s the running faucet? It is your carbohydrate intake. In most forms, carbohydrates are
broken down to glucose even before entering the bloodstream. And unlike fats and proteins,
carbohydrates have a hefty impact on blood glucose.

In simple high-school science, glucose is a monosaccharide, the simplest form of sugar.

Disaccharides, such as lactose, sucrose, and maltose, are two monosaccharides combined. All
disaccharides break down to at least one, if not two, glucose molecules.

Complex carbohydrates are at least three monosaccharides, which some say are healthier
because they aren’t broken down as quickly as simple carbohydrates. However, they do still
break down, at least partly, to glucose. So, simple or complex, carbohydrates are eventually
broken down to glucose.

The same can be said for high-glycemic versus low-glycemic carbohydrates. The glycemic
index indicates how foods compare to each other in terms of their effects on blood glucose.
Low-glycemic carbohydrates produce the smallest spikes in blood glucose. However, the low-
glycemic carbohydrates still directly impact blood glucose and studies show that replacing
carbohydrates with fats and protein is a more effective glycemic strategy [14,52].

Although proteins produce some glucose, they are very inefficient at it. After protein is digested,
it is broken down into amino acids and peptides. The amino acids and peptides are absorbed
and then either used for building new proteins or broken down even further. The amino acids
that are broken down become two structures. One of those structures is broken down into
carbon dioxide, fatty acids (which are the major building blocks of fats), ketones (depending on
the current supply of glucose), and glucose.

Although proteins produce some glucose, they are very inefficient at it.
To recap, proteins are digested into amino acids, absorbed, transported, split up for building
new tissue or for being broken down further, and the broken-down portion becomes two
segments, one of which is used for several new purposes, and one of those purposes is the
creation of glucose. That is a long sentence, but you get the point. Protein is extremely
inefficient for creating glucose, and therefore, is not very potent for raising blood glucose.

What about fat (lipids)? Triglycerides comprise about 95% of the fat found in food. Each
triglyceride is eventually broken down to three fatty acids and one glycerol (an alcohol
molecule). Eventually, the fatty acids are used for energy and the glycerol forms the backbone
of new triglycerides or becomes raw material for one of two biological processes (one of which
produces glucose when a person is exercising or is in danger of being hypoglycemic). Overall,
the components of fat do not directly affect blood glucose.

Based on your body’s digestion and metabolism of fats, proteins, and carbohydrates, it is the
carbohydrates that make the most physiological sense when looking for a party responsible for
increasing blood glucose. If this hypothesis is right, research will corroborate.

Let’s take a look at a few studies where people with type 2 diabetes consumed varying
carbohydrate totals.

1. A study at the University of Pennsylvania reported on 144 men and women with diabetes
who followed one of two nutritional recommendations: one with very few carbohydrates
(less than 30 grams per day) but ate as much protein and fat as they wanted, or a calorie-
controlled plan that required fat to be less than one-third of the calorie intake [27]. The men
and women who ate as much fat and protein as they wanted decreased their HbA1c 0.5%
in six months, while the calorie and fat-controlled group experienced basically no change.

2. In a New York-based study, diabetic men and women with an average age of 54 tried a
diet rich in carbohydrates or fat [11]. After three months, the “high fat” group ate an
average of 49% of their calories from fat and 24% from carbohydrates. The other group ate
25% of their calories from fat and 53% from carbohydrates. HbA1c at three months
decreased 0.64% in the high-fat group, which was more than double the decrease in the
high-carb group.

3. To look at a longer-term effect, diabetics were assigned to a high protein and fat or high-
carb lifestyle for one year in a study published by the journal, Nutrition & Metabolism [40].
The high-protein and fat group dropped their HbA1c 1.4% at six months (from 8% to 6.6%),
compared to a 0.9% decrease for the high-carbohydrate group. From 12 to 22 months, the
researchers did not regularly meet with the participants. At 22 months, all parties
reconvened and retested. After 22 months of observation, the high-fat and protein group
maintained a HbA1c of 6.9%, lost an average of 18.5 pounds, cut their average insulin
dosage from 60 to 27 IU per day, and about one-third decreased their blood-pressure
medications. Twenty-one of the 22 people in the high-fat and protein group weighed less at
22 months when compared to baseline. The researchers noted that the high-fat and
 protein lifestyle led to the decrease in insulin dosage, and the insulin decrease made it
physiologically possible for weight loss to occur.

In these studies, it’s likely that most of the participants ate less than what they were eating
previously. However, as mentioned, one of the studies did not recommend restricting calories
for the high-protein and fat eaters. Also, the third study allowed people to live their lives as
desired from 12 to 22 months, allowing for a more realistic application of the dietary
recommendations.

This all boils down to the fact that all of these people were able to improve their blood glucose
and HbA1c levels by performing one simple dietary change: replacing carbohydrate calories
with fat and protein calories. Protein may be ineffective at increasing blood glucose levels, but
carbohydrates strongly affect those levels. Fat has no direct effect either way.

Eating Pro LiVe Meals

I recommend that you follow a Pro LiVe eating plan. In other words, eat PROtein, LIpids, and
VEgetables. Remember these three and use them as replacements for some of the
carbohydrates in each meal. Not every item on your plate needs to be changed, but the more
you can follow the Pro LiVe approach, the more you will be optimizing your health for the better.

Mark’s dietary changes helped decrease his HbA1c from 7.2% to 5.2% and his morning blood
glucose from an average of 130 to an average of 85 mg/dl. In my opinion, Mark’s dietary
changes were one of the most important, if not the single most important, change in his lifestyle.
He replaced his usual carbohydrates with vegetables, healthy oils (lipids), or foods high in
protein. He replaced his toast and jam in the morning with eggs and bacon or Greek yogurt, and
switched the sugar in his coffee to cream. And even though he still enjoys pork chops, shrimp,
or beef for dinner, he replaces the fries, potatoes, or rice on the side with more meat or veggies
such as cucumbers, broccoli, or tomatoes. He also cooks and dresses his food with healthy oils.

Remember Tammy, our friend from Chapter 5 who was prediabetic despite weighing less than
100 lbs? In addition to strength training, Tammy adopted a Pro LiVe approach to restore her
blood glucose to a healthy range.

Prior to her dietary changes, some of Tammy’s dietary staples were bagels, rice, low-fat milk,
and several other carbohydrate-based foods. While eating this way, she constantly craved
sweets.

“I was often lightheaded and had a ‘foggy brain,’ which led me to crave sugars that would drive
my blood sugar up. I realized how much I craved sugar, and how they made me feel sleepy
after eating them, but regardless, I still wanted them.”

Tammy’s doctor recommended switching some carbohydrate-based foods for vegetables,

proteins, and fats, but that was difficult for Tammy to accept right away.
“I was reluctant to change my food choices. I knew what I liked to eat and I didn’t want to stop
eating all of the candy and processed foods. I changed because I knew I could end up with
diabetes like my father, aunt, and cousin. My cousin passed away at 49 years old because of
diabetes.”

Tammy still eats carb-based foods such as sweet potatoes on occasion, but the majority of her
diet became protein and fat foods.

“I eat the carb foods on occasion if I want them. However, I began eating a lot of foods like
avocados, fish, flaxseed, bacon, coconut oils, chicken, and ground meat. I could feel the
difference in my food cravings. Once I ate the fats and proteins, the sugar cravings went away. I
also began to feel much better physically and mentally. I wasn’t falling asleep after meals and I
could see my blood sugars not spiking as high as they were before.”

Tammy added that her blood glucose readings improved within a month.

Every 10% removal/replacement of carbohydrate calories produces average decreases of 4.5%

and an absolute reduction of 1.5% for fasting blood glucose and HbA1c, respectively, according
to researchers from Duke University [4]. As discussed in earlier chapters, a 0.3% drop in HbA1c
translates to a 6% decreased risk of premature death [23]. Using that formula, you could say
that every 10% replacement of carbohydrates may improve a diabetic’s risk of avoiding a
shortened lifespan by 30%.

Even a 10% replacement of the carbohydrates in your diet should bring large changes in
glycemic control.

Pro LiVe vs. Carbohydrate Restriction/Low-Carb Diets

Now, before you jump to any conclusions, the Pro LiVe approach is not a low-carb diet or a
carb-restricted diet.

Low-carbohydrate and carbohydrate-restricted diets typically require consuming less than a

specific amount of carbohydrate grams per day (i.e. 20 or 50). Also, you must reach the daily
total, regardless of what you currently do.

Pro LiVe has no recommended daily maximum or minimum of carbs allowed per day. It does
not focus on your daily carbohydrate intake. Pro LiVe is a meal-by-meal approach. Instead of
meeting a specific amount during the day, you work from where you are. In other words, act as
aggressively as you like. Even a 10% replacement of the carbohydrates in your diet should
bring large changes in glycemic control.

Pro LiVe is not a recommended restriction of carbohydrates. You don’t have to eat less. You
simply remove as many carbohydrates from your meal as you would like, and replace them with
foods that will have a lesser effect on your blood glucose. Specifically, replace your carbs with
natural proteins, oils, and vegetables.

Type 2 diabetics in a recent study, which was a low intensity version of Pro LiVe eating,
alternated substituting protein and carbohydrates for each other in two five-week studies. The
results were published in the American Journal of Clinical Nutrition. The first five-week study
offered a diet higher in protein where 30% of calories came from protein and 40% came from
carbohydrates. The second diet was a very high-carb diet with 15% protein and 55%
carbohydrates [21]. The HbA1c improvement was nearly three times greater in the high-protein
group (-0.8 vs. -0.3%). The high-protein meals also produced a 40% lower blood glucose
response.

Keep in mind the high-protein group achieved a 0.5% greater improvement in HbA1c by
changing only 15% of carbohydrates to protein (when compared to the other group). If the
participants substituted even more protein (or vegetables or healthy oils) for carbohydrates, the
blood-sugar reduction would have been even larger.

So what exactly should you be eating or replacing? Follow the steps and table below to eat Pro
LiVe meals:

1. Identify the major carbohydrate sources in your next meal.

2. Decide what/how much you are willing to replace.

3. Choose an alternative food in place of the carbohydrate source.

The table below features recommendations for replacements and additions to your diet.
Replacing the foods on the left with the foods on the right will lower the glucose spike following
a meal. I paired the foods in each row to provide specific options, but all foods in the right
column are blood-glucose friendly.
While vegetables mainly consist of carbohydrates, they generally do not raise blood glucose to
the same degree of other carbohydrate foods such as rice and pasta. In addition, they generally
are more satiating and less calorically dense, so you likely won’t eat as many carbs in
vegetables as you would in bread, pasta, or potatoes.

Here are some ways to use a Pro LiVe approach. Replace one or both slices of bread in a
grilled chicken sandwich with extra chicken, lettuce, and tomato. For a steak-and-potatoes
dinner, consider steak with spinach, carrots, onions, and/or mushrooms instead. If oatmeal is on
the breakfast menu, how about substituting an omelet with ground turkey and sliced bell
peppers? If you’re not willing to go that far, have a smaller serving of oatmeal and add a hard-
boiled egg or two.

It is important to remember that Pro LiVe meals are not about starvation or deprivation. You can
eat the same amount and still be satiated. Pro LiVe meals just provide your body with more
blood-glucose-friendly foods. Also, you can be as aggressive as you like. There is no minimum
amount required.

Pro LiVe meals offer the single-most effective maneuver for taking the lead in your battle
versus type 2 diabetes.

If you are ever in doubt whether what you are eating is healthy, there is a simple test to find out.
Check your blood sugar just before eating, and then check an hour after you started eating.
How much did your blood sugar increase? What was your post-meal blood sugar? Compare it
to the blood sugar ranges in the table in Chapter 1. Let your blood sugar tell you what foods
need to be avoided.

As I have mentioned throughout The Heart Healthy Lifestyle, it is your call to choose which
lifestyle options to implement. However, I strongly recommend Pro LiVe meals. If the
recommendations in this book are a baseball lineup, the Pro LiVe approach is the clean-up
hitter. This is the option that has the greatest potential for hitting a home run. While other
options in this book are potent, Pro LiVe meals offer the single-most effective maneuver for
taking the lead in your battle versus type 2 diabetes.

Fat for Your Heart’s Health

Throughout the chapter, I have mentioned fat, or lipids, as a replacement for carbohydrates.
There are a lot of questions about fat in mainstream media as a cause of heart disease.

As mentioned in Chapter 1, 75% of diabetics die as a result of heart disease [46]. As stated in
Chapter 2, heart disease is the pinnacle of the “benefits package” provided by type 2 diabetes.
However, a new study shows that fat, when supplemented into a Mediterranean diet, reduces
the risk of cardiovascular-related death up to 31% with a largely diabetic population [16].

This study, conducted in Spain with almost 7,500 people, followed all participants for an
average of 4.8 years. About half of the participants were diabetic. Those who weren’t diabetic
had a few of the following risk factors for heart disease: currently smoking, obese, high blood
pressure, high LDLs (commonly referred to as the “bad cholesterol”), or low HDLs (“good
cholesterol”). The participants followed one of three diets: Mediterranean diet with additional
extra-virgin olive oil (EVOO), Mediterranean diet with additional mixed nuts (MN), and a low-fat
diet (LF).

Compared to the LF group, the EVOO and MN groups had 30% and 28% lower rates,
respectively, of facing any of the following issues: stroke, heart attack, or cardiovascular-related
death. The EVOO diet had the strongest impact, reducing cardiovascular-related death risk by
31% and overall death rate by 18%.

Extra-virgin olive oil is entirely fat and the vast majority of calories in mixed nuts are from fat as
well. If fat is a cardiac killer, then the EVOO and MN groups would not have led to such great
reductions in cardiovascular events and death. In fact, the researchers actually credited the
reductions as being primarily due to the added olive oil and mixed nuts. Other than those
additions, there were only minor differences between the Mediterranean and low-fat diets.

There are two lessons to take away from the study in Spain. First, fat can contribute to your
heart’s health. Eating olive oil or nuts every day greatly benefited the study participants. Two of
the success stories featured in this book, Tammy and Mark, regularly eat olive oil, coconut oil,
grass-fed beef, and avocadoes, among other lipids.

Two lessons from the study in Spain:

1. Fats, such as healthy oils, improve your heart’s health.

2. Take a tablespoon of extra-virgin olive oil with each meal.

Second, take a tablespoon of extra-virgin olive oil with each meal. What is special about extra-
virgin olive oil? The researchers attributed the benefits attained by the EVOO diet to the oil’s
rich supply of polyphenols. Polyphenols are abundant sources of antioxidants and have anti-
inflammatory properties. Extra-virgin olive oil contains a much greater amount of polyphenols
than plain olive oil; so spend the extra dollars to get extra-virgin. The EVOO group consumed
about three to four tablespoons per day.

What About Sugar Alcohols and Artificial Sweeteners?

Look for sugar alcohols in processed foods that are usually promoted as “sugar-free,” such as
candy, gum, cookies, and ice cream. You can spot sugar alcohols in the ingredient list by
looking for xylitol, maltitol, mannitol, sorbitol, or lactitol. Sugar alcohols provide an advantage to
diabetics because they produce a slower rise in blood glucose than sucrose (table sugar). They
also have fewer calories per gram than sucrose. On the other hand, drawbacks include
diarrhea, gas, and abdominal cramps due to sugar alcohol’s attraction of water.

Artificial sweeteners are chemical creations that have the same calories per gram as sugar, but
are much sweeter so you end up using only a fraction of the amount. Manufacturers add these
sweeteners to processed foods such as diet sodas, candies, and gum. Common artificial
sweeteners include aspartame (NutraSweet and Equal), saccharin (Sweet’N Low), acesulfame
K, and sucralose (Splenda). These sweeteners range from 200 to 1,300 times the sweetness of
sugar.

The drawback of these sweeteners is that the body reacts by producing insulin. Keep in mind
that diagnosed diabetics have permanently worn out a large percentage of their Beta cells,
which are responsible for producing insulin. The body does not create new Beta cells, so once
the ones you have are worn out and cannot create insulin, you must inject insulin for the rest of
your life. Therefore, artificial sweeteners do not increase blood glucose, but they can still wear
down your Beta cells and worsen your diabetes.
Stevia (Truvia) is an artificial sweetener extracted from a naturally sweet plant. Stevia is
generally regarded as harmless when infrequently consumed.

Overall, artificial sweeteners and sugar alcohols do present alternative options to sugar for
diabetics when eating processed foods. If you were to opt for one, stevia and sugar alcohols are
the least detrimental choices.

However, I recommend eating a diet filled with real foods. Real foods, according to author
Michael Pollan in the book In Defense of Food, are individual foods that contain five or fewer
ingredients, with all ingredients being pronounceable and familiar. To decipher whether a food is
“real,” simply look at the nutrition facts label and count the ingredients. Examples of real foods
are fish, red meat, poultry, eggs, pork, vegetables, and nuts. In nature, real foods are close to, if
not exactly, in their natural state when eaten. I think you will find real foods to be more satisfying
and satiating than sweetened processed foods.

Improve or even eliminate your sugar cravings by simply switching to a diet based on real foods.
In addition, real foods are generally more nutritious and leave you more satiated while aiding in
the goal of improving your blood glucose.
 Chapter 9: Aids for Post-Meal Glucose

New York City is home to some of the world’s richest and most successful individuals in various
fields. This shouldn’t be a surprise because a strong work ethic is the forte of many New
Yorkers. Working just 40 hours in a week isn’t “the norm”—it’s rare.

While working as a personal trainer in NYC, my day was long: many clients needed 6 a.m. and
8 p.m. sessions because that was just before or after their workdays. I knew very few who left
work at 5 p.m.

As you would imagine, many of my clients were overworked. They were exhausted by
Wednesday, dragged themselves through Thursday and Friday, and atoned for the loss of rest
on Saturday and Sunday. On Monday, they were refreshed and ready to work. I was always
impressed with how they consistently exhibited resilience.

Your Beta cells don’t demonstrate the same resilience. As I said in Chapter 2, the Beta cells are
responsible for producing insulin and reside in your pancreas. Instead of recovering over the
“weekends,” or when the demand for insulin is low, your Beta cells remain fried. Once they are
chronically overworked to the point of not producing insulin, Beta cells won’t bounce back.
People typically have already burned out about half of their Beta cells when diagnosed with
diabetes.

Insulin is needed in large doses when blood glucose rises, and blood glucose rises after a meal,
especially one with a large amount of carbohydrates. The greater blood glucose rise, the greater
the need for insulin.

One of the most effective ways to minimize the workload of your Beta cells is to limit insulin
production following a meal is by minimizing the spike in blood glucose. Chapter 9 covers two
methods for minimizing the rise in blood glucose following a meal: vinegar and fiber.

Vinegar
That bottle of vinegar in your pantry may make a great salad dressing, or even clean your coffee
pot, but it is also, I kid you not, a fairly potent anti-diabetes weapon. If you are diabetic,
prediabetic, or concerned about developing type 2 diabetes, vinegar is your friend. There are
two important ways vinegar can effectively aid in your fight against diabetes.

Vinegar = a fairly potent anti-diabetes weapon.

A Carbohydrate Buffer
In Chapter 8, I told you to replace major carbohydrate sources with proteins, vegetables, and
fats in order to improve blood-glucose levels. However, you still may occasionally indulge in a
favorite food that is high in carbohydrates. What then? For those instances, vinegar is the
answer.

In a study published in Diabetes Care, 10 people with type 2 diabetes and 11 with insulin
resistance who had not yet developed diabetes received several high-carb foods [29]. The high-
carb meal consisted of a bagel with butter and a glass of orange juice, totaling 87 grams of
carbohydrates. When compared to a placebo drink that was predetermined to pose no real
glycemic advantages, the high-carb meal with an apple-cider precursor led to post-meal
improvements in blood glucose and insulin sensitivity.

The researchers concluded that, “Vinegar may possess physiological effects similar to Acarbose
or Metformin,” which are common diabetes medications.

A Bedtime Drink
In another study published in the journal Diabetes Care, researchers provided 11 type 2
diabetics with two experimental meals before going to sleep [53]. One meal was an ounce of
cheese, and the other was an ounce of cheese accompanied by two tablespoons of vinegar.
While the cheese did produce a small reduction in morning glucose levels, the effect of the
vinegar meal was twice as strong. The participants with a fasting blood glucose of 130 mg/dl or
greater experienced an average improvement of 6%, or a 9 mg/dl decrease for a person with a
fasting average of 150 mg/dl.

Vinegar: Why and How?

Vinegar’s active ingredient is acetic acid, which reduces starch digestion and may delay gastric
emptying (the rate of digested foods moving from the stomach to the small intestine). As a
result, the transfer of glucose to the bloodstream is reduced and scattered, which minimizes the
magnitude of the blood glucose response.

To receive the benefits of vinegar consumption, just consume two tablespoons of vinegar
immediately before bedtime or eating carbohydrates.

Although all forms of vinegar contain acetic acid, take red-wine vinegar or apple-cider vinegar
straight up since their tastes are not as strong as the others. Also, many other types of vinegar
have higher sugar values, which can reduce the blood glucose benefits of acetic acid. Don’t
confuse vinegar for vinaigrette, which is a salad dressing made with vinegar and several other
items and will not have the same effect.

If consuming vinegar directly from a tablespoon is not palatable for you, mix it with water and
experiment with other ideas to find what works for you.
Fiber
Carbohydrates will drive your blood glucose higher than other macronutrients (fat and protein),
but carbohydrates can also help control your blood glucose. Confused?

There is one exception to the Pro LiVe system of replacing carbohydrates: fiber. Fiber is a
carbohydrate that doesn’t act like other carbohydrates. Before I get into that, let’s discuss what
fiber is.

Fiber is a carbohydrate that doesn’t act like other carbohydrates.

Fiber is a complex carbohydrate that mainly comes from the cell walls of plants. Fiber is
complex in that it consists of several glucose molecules bound together. Unlike most other
carbohydrates, fiber passes through the digestive system basically unscathed - humans lack the
enzymes necessary to break down the bonds between fiber’s glucose molecules. As a result of
the failure to break down the bonds, the glucose molecules are not absorbed and cannot gain
access to the bloodstream.

Fiber is broken down into two types: soluble and insoluble. Soluble fiber slows the transition of
food from the stomach to the small intestine, increases the overall digestion time, and slows the
release of glucose into the bloodstream. Insoluble fiber increases the rate of digestion and is not
as desirable since it provides fewer health benefits.

Post-Meal Effects
A study published in the American Journal of Clinical Nutrition featured a random assignment to
one of two fiber supplements for eight weeks [2]. The supplements were psyllium husks, a
soluble fiber, or Avicel, an insoluble fiber. Each group took five grams of the assigned
supplement before breakfast and dinner.

The men were overweight, diabetic, and averaged 63 years of age. Before starting the study,
the men were studied for two days to determine their average blood glucose and insulin
responses to standard meals. At the end of the study, the men were fed the same meals and
responses were again studied for two days.

To ensure dietary consistency, all participants were encouraged to maintain their standard diets
and also received ongoing dietary counseling throughout the eight weeks.

All-day blood glucose, which is an average of blood glucose taken about every hour following
the first meal, was 4.2% lower in the soluble fiber group when compared to their own baseline
numbers. Post-lunch blood glucose was especially impacted, with a 6.5% reduction compared
to baseline numbers. All-day and post-lunch blood glucose readings in the soluble fiber group
were 11% and 19.2% lower than the insoluble group, respectively.

Like vinegar, fiber’s glycemic benefit extends beyond the post-meal effects.
Overall Blood Glucose
Like vinegar, fiber’s glycemic benefit extends beyond the post-meal affects. This was illustrated
by a Dallas-based study conducted with a crossover design [9].

A crossover design occurs when the same participants are used for the main experiment as well
as the comparison group. In between each testing period, a “washout” period occurs where the
benefits of the first treatment wear off. A crossover design is optimal in that no personal
differences between the groups will influence the outcome.

In this particular study the participants were mostly men, all had type 2 diabetes, and were
obese. The participants spent two six-week periods on one of two diets: a low-fiber diet with an
average of 24 grams of fiber (eight grams of soluble) per day, and a high-fiber diet averaging 50
grams of fiber (24 grams of soluble fiber) per day. Both diets featured breakdowns of 30% fat,
15% protein, and 55% carbohydrate calories.

When comparing the end totals of each diet, the participants had 10% lower blood glucose and
12% lower blood insulin measurements following the high-fiber diet.

Adding Fiber to Your Diet

To reap the benefits of fiber in your diet, I recommend two courses of action. First, add fiber-rich
foods to your diet that aren’t extremely high in non-fiber carbohydrates.

The optimal way to do this is adding high-fiber foods in place of other carbohydrate-rich foods
(to get an idea of high-carbohydrate foods that should be replaced, refer back to the Pro LiVe
food exchange table in Chapter 8). Some foods high in fiber include broccoli, artichokes,
avocados, raspberries, almonds, and sunflower seeds.

My second recommendation is to add a soluble fiber supplement. Metamucil and Secrets of the
Psyllium (a Trader Joe’s product) are two quality examples. Start with five grams of fiber per day
just before one meal. Consume water with and after the fiber. After a week at that level, add a
second serving of five grams. The second serving can be an add-on to the first serving, or
before a different meal.

Note: When increasing fiber intake, it is critical that you increase your water intake. Follow the
directions on the product label to determine how much water is needed with the fiber serving,
and then drink at least one additional glass of water to chase the fiber. Gastrointestinal
discomfort is common with a lack of water to complement a fiber supplement.

Closing Thoughts
Both vinegar and fiber have the power to improve your blood glucose level and decrease the
workload of your Beta cells. I don’t know of anyone, New Yorker or otherwise, who enjoys
working 60 hours a week. Why put your Beta cells through the relative equivalent when a few
small adjustments can keep them fresh and functional?
 Chapter 10: Everything in Life is Feedback

When we label efforts as successes or failures, we’re saying that those efforts are completed
and defined. For example, if you consider a recent weight-loss attempt to be a failure, you are
saying the attempt it over. However, even if you haven’t lost weight yet, nothing is stopping you
from making other changes to your eating and exercise habits today and continuing the effort. It
is still very possible for you to lose weight. Your attempt is not over – it just needs an adjusted
plan of attack.

In most cases, our efforts are not finished and definition is not required. Knowing this will help
you in your path to prevent or treat type 2 diabetes.

At this point, you may have already started implementing some of the lifestyle recommendations
from the previous chapters, or plan to begin. You could decide to try one suggestion at a time,
aiming to perfect it before moving onto another. However, you might take a different route and
opt to go for everything at once, or even end up somewhere in the middle.

No matter what approach you choose, it is likely that the lifestyle adjustment won’t be
completely seamless. Obstacles will pop up where you least expect them at some point in the
process.

For example, you may start strength training, but in your third week you have to skip the gym
after work a few times because your kids need rides to baseball practice. Perhaps you started
Pro LiVe meals but had a lapse by not subbing pasta and bread out of your meals on
consecutive days.

Don’t beat yourself up. Even though you may see these lapses as signs of doom in your new
lifestyle habits, they are not. These lapses provide important feedback and valuable information
for your journey.

The best action you can take is to listen to the feedback and adjust accordingly. If your kids
need rides to practice after school, then consider shortening your post-workday workouts,
workout in the morning, switch your workout days, or switch to a gym that is close to the fields
where your kids play baseball. If you find eating bread or pasta tempting, try eating more fish or
chicken instead, or try eating at restaurants that don’t put bread on the table or have your
favorite pasta on the menu. You might even try to eat with a different crowd who better
understand your need to find new options. Look at these lapses as challenges to be creative
and signals to alter your approach.
The largest flaw in making lifestyle changes is viewing them as successes or failures with no
exceptions. For instance, if going to the gym for 30 minutes after work won’t happen periodically
due to baseball practice, you can either look at it as a complete failure, OR you can make a few
adjustments to your lifestyle that allow you to continue lowering your blood glucose, losing
weight, and attaining all of the other benefits of an exercise program.

Nothing great comes without effort and obstacles.

Everything in life is feedback. Nothing great comes without effort and obstacles. Each of us is a
perpetual work in progress. Learn from the experiences in your life and make the necessary
adjustments.

Heart Healthy Tweets

In addition to your personal physician and The Heart Healthy Lifestyle: The Prevention and
Treatment of Diabetes, what if you could have a daily message to remind you about your health
and offer tips on staying healthy? That’s what Heart Healthy Tweets are all about: keeping you
healthy.

Before getting into the mechanics of Heart Healthy Tweets, let’s discuss why they help. The
Journal of Diabetes Science and Technology published an article that covered studies ranging
from three to 12 months long using short-message interventions with diabetics [32]. These were
mostly text messages covering a variety of purposes including education, information on blood-
glucose monitoring, motivation to exercise and eat well, foot-care information, and even
medication reminders.

The results were positive and pointed out the benefits of short messages since nine of 10
studies using cell-phone interventions led to improvements in HbA1c. Some of the specific
results achieved by each time range are listed below:

1. Three Months: Decreases of 2.15 (in individuals over 7.0%) and 1.15% in HbA1c, and
drops of 28.6 mg/dl and 78.4 mg/dl in fasting and two-hour, post-meal glucose
measurements. Also, hypoglycemic episodes decreased while days of exercise, foot care,
and taking medications increased.

2. Four Months: Total sitting dropped by 5.9 and 5.2 hours during the weekdays and
weekends.

3. 12 Months: HbA1c decreased in the text-message group by a total of 1.32%. On the other
hand, the control group—who received the standard care from medical professionals—
increased .8%.

Informational short messages are effective for improving self-care, increasing exercise
frequency, decreasing sedentary time, and ultimately improving blood glucose.
Taking part in Heart Healthy Tweets means once you have a Twitter account (twitter.com), you’ll
receive one Tweet every day with educational information you can use. Each tweet is no longer
than 140 characters and include tips about monitoring blood glucose, building confidence
related to carrying out desired lifestyle habits, providing specific examples for diet and exercise,
and sending insights for overcoming barriers to good health. If you’ve got a demanding job or
busy life, it may be difficult to keep up new lifestyle habits, and Hearth Healthy Tweets can keep
you on your path to better health in an easy format.

In the fight against diabetes, every resource helps. By reading this book, you are already taking
steps toward better health. Signing up for Heart Healthy Tweets is completely free. To become
a subscriber, follow @HeartHealthyTw on Twitter.

Don’t worry about having the perfect plan.

The important thing is to get started and make adjustments as you go.

Mark, whose story has been scattered through this book, is a friend of mine who I see at the
gym a few times a week. When we sat down to discuss all of the incredible changes that he has
made, he offered this insight into his success and feedback along the way:

“Before Dr. Hilts, if I ended up at a party and ’fell off the wagon,’ I would just stay off the
wagon. It was all lost. Through this process, I’ve learned that I will fall off the wagon, but
the next morning I can get right back on again. Not all is lost at that point. And now that it’s
been over a year of hard work, I eat so much better and I feel so much better. There’s no
comparison. Giving myself permission for small detours from the plan and then getting
back to business… that was a big deal for me.”

Take a lesson from Mark and look at obstacles as signals that adjustments are needed and not
as reasons to quit. Don’t worry about having the perfect plan, the important thing is to get
started and make adjustments as you go.

Obstacles, whether expected or not, will happen. However, they should not derail your efforts.
Change your habits and you will likely add years to your life, look better, and feel better. Not
only that, you will have more energy, less pain, a healthier blood glucose, and a brighter future
with your health. What you have to gain is much greater than any obstacles you face along the
way.

Enjoy the “new you.”

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Sean Preuss has a Master’s in Exercise and Wellness from Arizona State University and a
Bachelor’s in English from LIU Southampton College. He has instructed more than 9,000
personal training sessions using brief exercise and health coaching to help individuals achieve a
variety of health and weight goals. He has written more than 250 research-based articles for his
website, various gyms, and wellness centers across the United States. For more information
about Sean Preuss, go to www.thehearthealthylifestyle.com.