Scott Webb (Host): A diabetes diagnosis, a Type 1 or Type 2, is never easy, but living with and managing diabetes can be a little easier on patients and their families by understanding the role that exercise can play in mental and physical wellness for patients. And joining me today is Dr. Dessi Zaharieva.

She's a Stanford instructor, certified exercise physiologist, certified diabetes care and education specialist, a second degree black belt in taekwondo with a bronze medal at the world championships, and much like you or your children, she too is living with diabetes.

This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb.

Dessi, thanks so much for your time today. We're going to talk about diabetes and exercise. And we were just sort of discussing this a little bit that folks generally think of diet when we think about diabetes, but not so much about exercise. So it's great to have your expertise today and talk through some of this and just have you, as we get rolling here, maybe explain the difference between Type 1 and Type 2, and also maybe emphasize the prevalence of Type 1 diabetes in America.

Dessi Zaharieva, PhD: It's often a confusion when you hear about diabetes, even, you know, as someone living with Type 1 diabetes myself for over 25 years. Type 1 diabetes is more of kind of an autoimmune beta cell destruction of the insulin producing cells of the pancreas. So there's not much simplicity to that, but the idea that the insulin producing cells get destroyed by the body, the actual etiology or why this occurs is still not fully clear, but you know, partially genetic, partially environmental, but it is your own body attacking those cells.

And this is ultimately what leads to people with Type 1 diabetes requiring insulin dependence, so needing to take exogenous insulin through injections or other means. Whereas Type 2 diabetes is more of a progressive loss of beta cell insulin secretion, so it's more to do with insulin resistance when it comes to Type 2 diabetes.

The cells may still be producing insulin, the body just may not know what to do with it as well. And when it comes to the prevalence, Type 1 is less prevalent than Type 2 diabetes, but even that it's growing every year. We see nearly 1.9 million Americans with Type 1 diabetes and close to 300,000 children and adolescents with Type 1 diabetes. And those are statistics based on 2019. So we can imagine those numbers are even higher today.

Host: Sure. Yeah, and I talked to an expert recently and it sort of blew my mind a little bit because when I think about Type 1, Dessi, I think about children, right? That it's often children who are diagnosed when they're children and then they end up sort of living with it and managing it their entire lives. This expert told me that many adults are actually diagnosed with Type 1 more than probably people would even realize. Has that been your experience?

Dessi Zaharieva, PhD: When I was diagnosed, sure, I was seven years old and I sort of fit that criteria that we initially thought was Type 1 diabetes occurring in pediatrics, but nowadays we absolutely see many, you know, older adults and even above teenager adults and older adults being diagnosed with Type 1 diabetes, I would say not as frequent.

We still see a kind of more of the diagnosis at younger ages, but it's absolutely more like it is common to see that diagnosis can occur later in life as well, which is one of the reasons that Type 1 diabetes is no longer called juvenile diabetes as it used to be back in the day.

Host: Right. Yeah, that's how I remember it is, is a juvenile thing, a childhood thing. And, most of us, when we think about diabetes, especially Type 1, we think about, well, managing our diet and eating right. And I'm sure that's a big part of it, but also exercise is a big part as well. And just want to have you kind of break that down, the role of exercise when it comes to managing Type 1.

Dessi Zaharieva, PhD: you're right that, nutrition and diet is important. So I really don't want to downplay that, but I also really appreciate just the focus on exercise as it's usually not as much of a focus as the idea of food and how that can impact blood sugars when it comes to diabetes. I guess I'll start with saying that exercise leads to numerous health benefits.

 We know that from you know, just day to day literature, what we hear, what we see people talking about and those benefits, whether it's Type 1 diabetes or no diabetes, we see that exercise can help increase cardiovascular fitness, improve psychosocial well-being, can help to decrease body fat.

But then there are some specifics, you know, whether it's in pediatrics or specific to Type 1 diabetes that are a little bit unique. So one of the things I often like to discuss is that exercise in terms of how it can help people with Type 1 diabetes is we can see increases in insulin sensitivity. And the way I like to describe that is your body uses insulin better.

The way when you exercise, your blood sugars can come down sometimes depending on the type of exercise you're doing. And when your blood sugars are a little bit higher and you exercise and bring your blood sugars down into a target range, you may feel a little better as well. We also see that, you know, overall there is just many other outcomes that can come from exercise and regular exercise. So, reducing the risk of diabetes related complications. Often in pediatrics, we don't discuss those complications as much as we do with adult, and Type 1 diabetes. But the more regularly we exercise, we reduce the risk of any of those diabetes related complications.

So, I always like to focus on those specifics around diabetes, but we know that exercise is good for everyone.

Host: Yeah. I never get an expert on here, a doctor or otherwise who says, ah, exercise, you know, overrated. No, they all, they all kind of say the same thing. The same message is clear that exercise is good. I know that you went through this. And so maybe you have a unique sort of personal perspective, but generally speaking, what are the most common questions that you get from newly diagnosed patients?

Dessi Zaharieva, PhD: It's a great question because there are many, but you know, I think there's two sides I like to focus on and one is that at new diagnosis, you kind of don't know what you don't know. So there is kind of one side of it where you may not know that exercise can actually, in fact, cause disturbances sometimes to your blood sugars.

And so, you know, some families don't really have too many concerns or worries at the beginning at new diagnosis, understandably because they don't know how the body's going to respond to exercise. But on the flip side of that, I do have many families that come in and you know, gung ho, they just want to know what is going on with my child's blood sugars.

They didn't stop exercise from the day of diagnosis and they're noticing blood sugars going up and down and blood sugars doing all these crazy things. And why is that happening? Can my child continue to play sports? How can they do so safely? So all of these questions are really valid and understood.

And I try to provide support on how they can exercise safely. And surprisingly, I also get questions on what type of technology can my child use that may help them manage their diabetes? So for example, at Stanford specifically, we have a big focus on technology, just in the Bay Area in general, we see a big push for technology to help with diabetes management.

So the difference is, I was originally from Canada and moved to the U.S. I can say that now that I'm at Stanford, it's almost one of the first things we talk about at new diagnosis with families. They want to know what devices they can use. Is it too quick to get started on them? How do they work? And a lot of those types of questions as well.

Host: Yeah. Yeah. Especially, just the smartphones and smartwatches and, all this sort of wearable technology, especially, you know, where Stanford Children's Health is, of course, you know, that's going to be top of mind. Absolutely. I feel like we've done some myth busting already, but are there any other myths we can bust, so to speak, about diabetes management and exercise?

Dessi Zaharieva, PhD: There's always myths that we can bust, you know, I think the education piece is what's most important and one of the reasons I do the research I do, I want to make sure we debunk those myths and people with diabetes can feel that they can exercise safely and not worry about what others may think.

So one of the first myths I always like to bust is that you can't exercise with diabetes. That's seems quite like who would say that, but the reality is we hear it a lot. How can you exercise with diabetes? You should be benched today because now you have diabetes. How can you exercise with diabetes?

But the reality is, yes, different types and intensities of exercise can impact blood sugars differently, but we've also done a lot of research to understand how we can do so safely. And I would say another myth that I always like to bust is people don't respond differently to exercise. And that's part of the reason why we have to keep doing the research that we're doing.

So some people think that, you know, what happens to me might happen to you. But the reality of diabetes is that, I mean, I could do the same thing today and tomorrow still have very different blood sugar responses. Now, I can do something and you can do something, and we could also have very different responses from person to person. So this is one of the reasons we continue to research in this field is just to understand all of those individual differences.

Host: Yeah, you must have read my mind. I had research on my mind. I want to give you a chance here, talk about your research, the work you're doing with this 4T exercise study, share that with our audience.

Dessi Zaharieva, PhD: So the 4T exercise study, you might wonder what that 4T stands for.

Host: I do.

Dessi Zaharieva, PhD: The Teamwork, Targets, Technology, and Tight Control. So that's our 4T, and then exercise, it's a sub-study of the main 4T study. It's a pretty large and very busy study, a lot of things are going on. At new diagnosis, we are starting these kids on continuous glucose monitoring systems that helps to track glucose levels pretty much every five minutes. We get updated glucose readings on a smart device. And they're able to track their blood sugars more regularly, more consistently to see those fluctuations and changes over time. We get them started on this technology early in diagnosis. And when I started at Stanford, I said, this is all great and it's important that we do this.

But where's the exercise piece? You know, with new diagnosis, I decided why not start these kids on activity trackers and why not integrate exercise education as part of this intervention? We know, just like you mentioned, Scott, we have to see dietitians and diabetes educators and endocrinologists, but where's the exercise physiologists or where's the discussion on exercise and how important it is and how difficult it can be to manage blood sugars with exercise. So part of that 4T exercise study is to deliver a structured exercise intervention four times throughout the year, where we're educating families on how to exercise safely so they can learn to kind of make their own, adjustments to their insulin needs, what foods to eat, all of these things go hand in hand, but there's a bigger focus on exercise.

Host: Yeah, for sure. How about any other research that you're involved in? You know, I know that you're very ambitious and very busy, but if there's anything else you want to share, things that you're involved in, things that would definitely benefit patients now and maybe in the future?

Dessi Zaharieva, PhD: We've done lots of studies and always keeping busy. So it's not always related to exercise. My area of research is exercise in Type 1. So some of the studies that we recently kind of wrapped up are related to for example swimming and a specific insulin pump type that they are using in one of our studies. How does that insulin pump work for kids that are swimming? And, a lot of it has to do with different types of exercise. So that was a study on swimming. We've done a lot with sort of bike and treadmill type exercise because we know that the type and intensity of exercise matters. But we've also done a lot with kind of the adjustments that need to be made for exercise.

For example, when to set a higher exercise target on an insulin pump or, you know, what foods need to be eaten for exercise to reduce the risk of maybe a low blood sugar; a lot of it has to do with glucose management around exercise, maybe different types of exercise, different durations, but all of my work is focused in that field.

Host: Yeah, that's awesome. And, you know, we've kind of been speaking a little bit more broadly. We've smart this and smart that. Maybe we could talk a little bit more, drill down just a little bit, the specifics when it comes to diabetes technology, how it's impacting diabetes management, you know, generally, the integration of exercise into that. Maybe we can speak in a little more specifics.

Dessi Zaharieva, PhD: one of the big things is that, you know, 25 years ago when I was diagnosed, we didn't have a lot of the technology I'm talking about right now, and we can dive into that a little bit deeper. But, initially at new diagnosis, you get started on what we call multiple daily injections. You have to take injections multiple times a day. And now one of the differences is, you know, this day and age, we have more technology to offer these newly diagnosed kids. So part of that is, again, like I mentioned, continuous glucose monitoring or CGM systems. It's a device that sits on the skin just underneath the skin and reads glucose readings every five minutes.

It reads interstitial glucose, so not exactly blood glucose, and it can tell us sort of what's happening every couple of minutes. Blood sugars are going up or down. We can see the trends. And then you know, kind of an additional piece to all of this technology is more kids are getting started on automated insulin delivery systems.

So what that usually encompasses is an insulin pump that communicates with your continuous glucose monitoring system. So these two devices kind of speak to each other. And there's an algorithm built into this insulin pump that can help to determine if your blood sugars are going up, the insulin pump can now deliver a little bit of insulin.

And part of the reason these automated insulin delivery or AID systems are so great is that it can help ease some of the burden and the weight off of these families and kids with diabetes. You know, they don't have to think of every step of the way, what did they eat? What are they doing? And so that's some of the technology that now we're integrating with exercise.

How can it help with exercise? How is it still challenged with exercise? And that's where a lot of the work is still being done.

Host: You know, neither of my kids had diabetes, but they played with kids who did. And I coached some teams and, you know, I just found that just being a coach, you had to have a sort of understanding of things and patience, definitely. Cause sometimes when you want that kid to run out in the field, but it's time to check their blood sugar and, you know, time to manage their diabetes. And, sort of the common thread here, as we've been discussing here is that kids can play sports, they can be athletic, they can exercise, and there just have to be some accommodation, some understanding. And that kind of leads me to my next question, because you were talking about your background with diabetes.

And I know that sports is a big part of your life. So for those kiddos with Type 1 diabetes, or maybe anyone, but especially kids, you know, what could they really learn from you and your experiences and how to stay active with diabetes?

Dessi Zaharieva, PhD: I think one of the biggest things for me is even without as much support as we can offer now in terms of exercise education, and support around exercising safely with diabetes, my family always pushed me, like, as a family unit, we were going to figure this out together. And one of my biggest takeaways is, you don't have to be an elite athlete to you know, manage your diabetes well.

And that's not the goal of the research or the work that I do. I'm here to support everyone with diabetes, whether that's someone just simply trying to increase their daily step count or sometimes it is looking at, you know, how to support an elite athlete with Type 1 diabetes. We've done it all and we're here to support everyone.

But, sometimes it can be scary when you think about, oh, this exercise physiologist and diabetes researcher is gonna maybe be ashamed that I'm not running a marathon every day. But the reality is that's not what our focus is. We are here to support everyone at whatever stage in life they're at.

And I think a big thing is you can do it. We are here to just support you each step of the way. Whatever challenge that may be. Is it how to use your diabetes devices and your accelerometers. Or is it how to increase your daily step count? Or is it how to compete at the highest level so, you can make a professional team, for example. We're here through all of those avenues.

Host: Yeah. As you say, like there's no judging, whatever level you're at, you're there to help them, whether it's just to understand the technology, how to incorporate exercise and sports into their lives and so on. So all good stuff and really educational today. Just talk about your goals for the future of diabetes and exercise management, both the research, clinical applications, you know, all the above.

Dessi Zaharieva, PhD: I think for me, my biggest aspirations are continue to kind of advocate for safe exercise for everyone with diabetes that they can do whatever they put their minds to. And one of the biggest things is that in the field of diabetes and exercise, there are so many differences in what kids may be doing. Different types of sports, different intensities, different challenges that people may face. And we're here again to offer as much support as we can so people can feel like they're not in this condition alone. And I know that for me growing up, I did feel like I was alone for a lot of this journey.

There was less research done. We just didn't know nearly as much as we know today. That doesn't mean we have all the answers. We still have a lot that we need to do. For me, my biggest aspirations are not only helping those kids at Stanford Children's, which of course is very important for me, but we started this from a small research study that's now grown to, we are running exercise education classes within Stanford Children's Clinic, and we are trying to more broadly provide this type of education and support to help all kids with diabetes. That doesn't need to be just newly diagnosed kids. That can be eventually adults with Type 1 diabetes. That can be, you know, anyone that's living with Type 1 diabetes that just needs a little bit of extra support and guidance on how to exercise safely. So ultimately if we could scale the work that we're doing nationally, internationally, of course, these are our future goals within Stanford.

Host: So, Dessi, just as we wrap up here, you know, especially someone newly diagnosed, a kiddo newly diagnosed, or their family or just folks in general, what would be your parting sort of words of wisdom? Because I'm sure there's a big amount of fear. Like we've talked about today that it's okay for folks with Type 1 diabetes and even Type 2 as well, you know, to exercise, but I'm sure there's the fear. We sort of busted some myths earlier, and we've kind of taken this on, but just your parting, closing thoughts here, words of wisdom, words of encouragement for anybody who's fearful about exercising, about participating in sports, about getting those steps in. What would you say?

Dessi Zaharieva, PhD: Yeah, I think my parting words on, you know, just anyone newly diagnosed with Type 1 diabetes is don't give up. Each day is a new day to learn something about how to manage this condition. And I've been living with this condition for over 25 years. I don't have all of the answers, but I've learned a whole lot more in these 25 years of diabetes and it has become easier.

So, just know that fear and those stresses at the beginning of a new diagnosis are understandable. They are completely valid, but know that, you know, there are a great community out there and people to support you. And we are all here. You know, you can reach out to me directly.

You can talk to your diabetes care team to find out how to manage your diabetes around exercise, but just know that it does get easier with time and, you know, take it one step at a time. It doesn't have to be a big life goal or life achievement. It can be something as easy as just taking a couple of extra steps today, you know, getting up and doing it and knowing that we can feel better after it.

Host: Yeah, absolutely. As someone who had family members who had diabetes, my grandfather had it when I was a kid. And I just think about watching him trying to manage his diabetes in the seventies versus what you're describing today and everything that's available to children, families, adults, everybody, and the possibility of being able to scale this research up to go global, if you will, it's really amazing. Brought a big smile to my face. Thank you so much. You stay well.

Dessi Zaharieva, PhD: Thanks, Scott. It was a pleasure.

Scott Webb (Host): And for more information, go to diabetes. stanfordchildrens. org.

Host:  And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.