Exercising with Diabetes

Meet Dr. Ryan Attar

Dr. Ryan Attar has lived with type 1 diabetes since 1980 when he was 27 years old and serving overseas as a captain in the U.S. Army. Discharged, immediately following his diagnosis, Dr. Attar spent the next several years training to become a naturopathic doctor and nutritionist, opening his Connecticut office in 2019. Dr. Attar doesn’t let his type 1 diabetes slow him down.

 

Dr. Attar’s Nutrition Plan

“I eat a low-carbohydrate, high-protein diet. I don't exactly call what I do ketogenic, even though I am probably in ketosis quite a bit,” explains Ryan. “I never chase ketone numbers or worry about being in ketosis, but instead aim for normal, non-diabetic blood sugars (80s and 90s) and a non-diabetic HbA1c.” Using this at-home kit, Ryan’s recent A1c level was 4.8 percent. 

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“My diet is always high-protein and very low-carb; I keep fat generally lower than a pure ketogenic diet unless I’m exceptionally active for no reason other than fat is a very dense calorie source. It’s easy to overdo fat and not stay as lean as I like to be.”

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Dr. Attar is a big fan of Dr. Bernstein and has adopted much of the diabetes guru’s nutritional philosophies. Learn more about Dr. Bertstein’s solutions here.

 

Dr. Attar’s Management Plan

Dr. Attar is not a big fan of insulin pumps. Instead, he uses multiple daily injections with Tresiba insulin for long-acting insulin needs and old-fashioned “regular” insulin for most of his meals since he eats fewer carbohydrates and more proteins and fats, which are digested slowly. He also keeps a rapid-acting insulin, Aspart, on-hand to correct high blood sugars when he exercises. In addition to his glucometer, Ryan wears a continuous glucose monitor (CGM).

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Exercise Strategies 

“For the past year, I've been doing Brazilian Jiu-Jitsu a couple of times per week. I also weight train three to four times a week and include one to two weekly cardio and conditioning workouts. Managing exercise like managing my blood sugar around new foods—especially while on a low-carb diet where I’m dosing insulin for protein—involves a lot of trial and error.”

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In other words, sometimes things don’t go perfectly. However, applying his knowledge about diabetes and exercise physiology, Dr. adjusts his plan to get the blood sugar outcome he wants.

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“Similar to food, predictability plays a big role in daily blood sugar management,” he adds. “The more you can control the variables around any given exercise or workout session, the more you can predict what it will do to your blood sugar.”

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Dr. Attar makes it a point to exercise when he’s fasted, exercising either first thing in the morning on an empty stomach, with in-range blood sugar, or in the evening before eating dinner (meaning he hasn’t taken any short- or rapid-acting insulin in the 4 to 5 hours since lunch).

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Weightlifting Personal Tip 

 “When I lift heavy weights, I know I’ll need an insulin bolus before the workout to compensate for that anaerobic blood sugar spike. By taking insulin before these sessions, I can keep my blood sugar in the 80s and 90s throughout my workout and beyond.”

 

Jiu-Jitsu Personal Tip 

“For jiu-jitsu and cardio workouts, which are both very aerobic, I monitor my blood sugar closely, keeping pure glucose (dextrose) close by. My blood sugar is normally pretty stable unless I have some insulin on-board from eating or correcting before my workout.”

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Dr. Attar’s diet is so low in carbohydrates that the amount of insulin he takes to keep spikes in check is minimal. He has less in his system at any given point in the day compared to someone who eats 30 grams of carbs at lunch or 45 grams at dinner.

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“Having so little insulin on board while on a low-carb diet means my blood sugar doesn’t tank when I start exercising. If it does drop, it’s very minimally and is easy to correct with a small amount of fast-acting glucose.”

 

Morning Workouts Versus Evening Workouts

“There’s not much difference between the two. I prefer to work out in the morning before I eat breakfast because of how little it impacts my blood sugar. If I work out in the afternoon or evening, generally 4-5 hours have passed since lunch, so my blood sugar isn’t likely to drop because there aren’t any large boluses of insulin on-board.”

 

Low Blood Sugars Hacks

“My weapon of choice to treat low blood sugar levels is Smarties candy. Unlike most candies that use sucrose, Smarties uses dextrose, the fastest-acting source of carbs to raise your blood sugar. It’s the same ingredient you’ll find in glucose tablets from pharmacies, but Smarties are much cheaper!

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I purchase Smarties in bulk bags. One roll provides 6 grams of carbs, and if I only need three or four grams of carbohydrates to treat a mild low, the little candies are easy to divide,” explains Dr. Attar, who is diligent about correcting lows without seeing his blood sugar go too high. He also notes he doesn’t particularly like Smarties, which works in his favor because he views these candies as a tool not a treat.

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 “Traditional diabetes education tells patients to treat lows with 15 grams of carbs. But if you treat all lows with that many grams, you’ll find yourself up at 150 mg/dL of carbs or higher when its best to keep carbs under 100 mg/dL.

 

“If you're taking sucrose (think: juice) to treat your lows, only half of that sugar molecule raises your blood sugar (the glucose portion). The other half (fructose) isn't directly raising your blood sugar and isn’t healthy for anyone. Before you use pure fructose to sweeten things to avoid a blood sugar spike, remember: fructose also raises triglycerides, is metabolized in the liver, and promotes fatty liver disease. Glucose goes directly to the bloodstream to raise your blood sugar.”

 

Correcting a High Blood Sugar Before Exercise

“I would personally only adjust an insulin dose for my cardio and jiu-jitsu workouts,” explains Dr. Attar. Since cardio and jiu-jitsu are both aerobic, they burn more glucose for fuel, potentially lowering your blood sugar if you have too much insulin on-board.

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“For strength training, I would add the correction dose of insulin to my usual pre-strength-training. But,” the doctor adds, “I’ve gotten into the habit of always correcting and waiting before exercising or eating.”

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What Everyone Needs to Know 

“Normalizing your blood sugar levels to non-diabetic levels during and after exercise is definitely possible.” Dr. Attar encourages patients to take good notes during and after new exercise routines just as they would with new diets.

 

"If you’ve gone high or low, note the variables during those work

outs (cardio vs. strength training, for instance—what you ate, how you dosed for what you ate, etc.), then make adjustments next time.”

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