Diabetes and Digestive and Kidney. Diseases (NIDDK) of toll for diabetes, considering both diabetes care, refer to the online resources and. cited …
12 Weight Loss — If You Overweight re
Weight loss can significantly reduce your insulin resistance You may recall from Chapter 1 that obesity, especially abdominal truncal, or visceral obesity, causes insulin resistance and thereby can play a major role in the development of both impaired glucose tolerance and type 2 diabetes If you have type 2 diabetes and are overweight, it is important that weight loss become a goal of your treatment plan Weight reduction can also slow down the process of beta cell burnout by making your tissues more sensitive to the insulin you still produce, allowing you to require and therefore to produce or inject less insulin It may even be possible, under certain circumstances, to completely reverse your glucose intolerance Long before I studied medicine, I had a friend, Howie, who gained about 100 pounds over the course of a few years He developed type 2 diabetes and had to take a large amount of insulin 100 units daily to keep it under control His physician pointed out to him the likely connection between his diabetes and his obesity To my amazement, during the following year, he was able to lose 100 pounds At the end of the year, he had normal glucose
tolerance, no need for insulin, and a new wardrobe This kind of success may only be possible if the diabetes is of short duration, but it is certainly worth keeping in mind– weight loss can sometimes work miracles Before we discuss weight loss, it makes sense to consider obesity, because if you don t understand why and how you are overweight or obese, it will be somewhat more difficult to reverse the condition THE THRIFTY GENOTYPE When I see a very overweight person, I don think, ought to control his eatingI think, t He He has the thrifty genotypeWhat is the thrifty genotype? The hypothesis for the thrifty genotype was first proposed by the anthropologist James V Neel in 1962 to explain the high incidence of obesity and type 2 diabetes among the Pima Indians of the southwestern United States Evidence for a genetic determinant of obesity has increased over the years Photographs of the Pimas from a century ago show a lean and wiry people They did not know what obesity was and in fact had no word for it in their vocabulary Their food supply diminished in the early part of the twentieth century, something that had occurred repeatedly throughout their history Now, however, they weren
faced with famine The Bureau of Indian t Affairs provided them with flour and corn, and an astonishing thing happened These lean and wiry people developed an astronomical incidence of obesity– 100 percent of adult Pima Indians today are grossly obese, with a staggering incidence of diabetes Fully 65 percent of adults are type 2 diabetics Since the publication of the first edition of this book, even many Pima children have become obese, type 2 diabetic teenagers A similar scenario is now playing out across the United States in the general population The pace may be slower, but the result is similar
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
What happened to the Pimas? How did such apparently hardy and fit people become so grossly obese? Though their society was at least in part agrarian, they lived in the desert, where drought was frequent and harvests could easily fail During
periods of famine, those of their forebears whose bodies were not thrifty or capable of storing enough energy to survive without food died out Those who survived were those who could survive long periods without food How did they do it? Although it may be simplifying somewhat, the mechanism essentially works like this: Those who naturally craved carbohydrate and consumed it whenever it was available, even if they weren hungry, would have made more insulin and thereby stored more fat Add to this the t additional mechanism of the high insulin levels caused by inherited insulin resistance, and serum insulin levels would have become great enough to induce fat storage sufficient to enable them to live through famines See Figure 1-1 Truly survival of the fittest– provided famines would continue A strain of chronically obese mice created in the early 1950s demonstrates quite vividly how valuable thrifty genes can be in famine When these mice are allowed an unlimited food supply, they balloon and add as much as half again the body weight of normal mice Yet deprived of food, these mice can survive 40 days, versus 710 days for normal mice Recent research on these chronically obese mice
provides some tantalizingly direct evidence of the effect a thrifty genotype can have upon physiology In normal mice, a hormone called leptin is produced in the fat cells also a hormone human fat cells produce, with apparently similar effect The hormone tends to inhibit overeating, speed metabolism, and act as a modulator of body fat A genetic flawcauses the obese mice to make a less effective form of leptin In recent experiments, when injected with the real thing they almost instantly slimmed down Not only did they eat less but they lost as much as 40 percent of their body weight, their metabolism sped up, and they became much more active Many were diabetic, but their loss of weight and the change in the ratio of fat to lean body mass reversed or even curedtheir diabetes Normal mice injected with leptin also ate less, became more active, and lost weight, though not as much Research on humans has not advanced sufficiently to provide conclusive evidence that the mechanism is the same in obese humans, but researchers believe it is at least equivalent and probably related to more than one gene, and to different gene clusters in different populations In a full-blown famine, the Pima
Indian ability to survive long enough to find food is nothing short s of a blessing But when satisfying carbohydrate craving is suddenly just a matter of going to the grocery or making fried bread, what was once an asset becomes a very serious liability Although current statistics estimate slightly more than 60 percent of the overall population of the United States as chronically overweight, there is even greater reason to be concerned, because the number has been increasing by 1 percent each year Some researchers attribute rising obesity in the United States at least in part to increasing numbers of former smokers Others attribute it to the recent increase in carbohydrate consumption by those trying to avoid dietary fat Whatever the reasons, overweight and obesity can lead to diabetes The thrifty genotype has its most dramatic appearance in isolated populations like the Pimas, which have recently been exposed to an unlimited food supply after millennia of intermittent famine The Fiji Islanders, for example, were another lean, wiry people, accustomed to the rigors of paddling out against the
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book
may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
Pacific to fish Their diet, high in protein and low in carbohydrate, suited them perfectly After the onset of the tourist economy that followed World War II, their diet changed to our highcarbohydrate western diet, and they too began and continue to suffer from a high incidence of obesity and type 2 diabetes The same is true of the Australian Aborigines after the Aboriginal Service began to provide them with grain Ditto for South African blacks who migrated from the bush into the big cities Interestingly, a study that paid obese, diabetic South African blacks to go back to the countryside and return to their traditional high-protein, low-carbohydrate diet found that they experienced dramatic weight loss and regression of their diabetes It clear that thrifty genotypes work in isolated populations to make metabolism supremely s energy-efficient, but what happens when the populations have unrestricted access to highcarbohydrate
foods? It would appear that the mechanism of the thrifty genotype works something like this: Certain areas of the brain associated with satiety– that sensation of being physically and emotionally satisfied by the last meal– may have lower levels of certain brain chemicals known as neurotransmitters A number of years ago, Drs Richard and Judith Wurtman at the Massachusetts Institute of Technology MIT discovered that the level of the neurotransmitter serotonin is raised in certain parts of the hypothalamus of the animal brain when the animal eats carbohydrate, especially fast-acting concentrated carbohydrate like bread Serotonin is a neurotransmitter that seems to reduce anxiety as it produces satiety Other neurotransmitters such as dopamine, norepinephrine, and endorphins can also affect our feelings of satiety and anxiety There are now more than one hundred known neurotransmitters, and many more of them may affect mood in response to food in ways that are just beginning to be researched and understood In persons with the thrifty genotype, deficiencies of these neurotransmitters or diminished sensitivity to them in the brain causes both a feeling of hunger and a mild dysphoria–
often a sensation of anxiety, the opposite of euphoria Eating carbohydrates temporarily causes the individual to feel not only less hungry but also more at ease A frequent television sitcom scenario is the woman just dumped by her boyfriend who plops down on the couch with a pie or half a gallon of ice cream, a spoon, and the intention of eating the whole thing She not really hungry s She depressed and trying to make herself feel better She indulging herself, we think, s s rewarding herself in a way for enduring one of life traumas, and we laugh because we s understand the feeling But there is a very real biochemical mechanism at work here She craves the sugar in the pie or the ice cream not because she hungry but because she knows, s consciously or not, that it really will make her feel better Contrary to popular belief, the fat in the ice cream or in the crust of the pie doesn make much of a difference It the carbohydrate that t s will increase the level of certain neurotransmitters in her brain and make her feel better temporarily The side effect of the carbohydrate is that it also causes her blood sugar to rise and her body to make more insulin; and, as she sits on the couch,
the elevation in her serum insulin level will facilitate the storage of fat On television the actress may never get fat But for the real-life woman, high serum insulin levels from eating high-carbohydrate foods will cause her to crave carbohydrate again If she is a type 1 diabetic making no insulin, she have to inject a lot of insulin to get her blood sugar down, with ll the same effect– more carbohydrate craving and building up of fat reserves
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
GETTING IT OFF AND KEEPING IT OFF There may be many mechanisms by which the thrifty genotype can cause obesity The most common overt cause of obesity is over eating carbohydrate, usually over a period of years Unfortunately, this can be a very difficult type of obesity to treat If you overweight, you probably unhappy with your appearance, and no less with your high re re blood sugars Perhaps in the
past you tried to follow a restricted diet, without success ve Generally, overeating follows two patterns, and frequently they overlap First is overeating at meals Second is normal eating at mealtime but with episodic grazing Grazing can be anything from nibbling and snacking between meals to eating everything that does not walk away Many of the people who follow our low-carbohydrate diet find that their carbohydrate craving ceases almost immediately, possibly because of a reduction in their serum insulin levels The addition of strenuous exercise sometimes enhances this effect Unfortunately, these interventions don work t for everyone Medications If you a compulsive overeater, if you just can stop yourself from eating, and are addicted to re t carbohydrate, you may not be able to adhere to our diet without some sort of medical intervention see Chapter 13 Carbohydrate addiction is just as real as drug addiction, and in the case of the diabetic, it can likewise have disastrous results In actual fact, excess body weight kills more Americans annually from its related complications than all drugs of abuse combined, including alcohol You need not despair of never losing weight, however
I have seen a number of dietproofpatients over the years get their weight down and blood sugars under control Over the last several years, medical science has gained a much more sophisticated understanding of the interactions of brain chemicals neurotransmitters that contribute to emotional states such as hunger and mood Many relatively benign medications have been successfully applied to the temporary treatment of compulsive overeating There is no doubt that when used properly, many appetite suppressants are quite effective in helping people to lose weight If you simply cannot lose weight, it may be helpful to discuss with your physician medicines that may be of use to you I have used more than 100 different medications with my patients and have found many of them to be of great value for treating carbohydrate addiction There is, however, a catch to this method Over the years, I have found that none of these medications works continually for more than a few weeks to a few months at a time, a fact that many if not most medical and diet professionals may be unaware of I developed a reasonably successful method for prolonging effectiveness of some by rotating them w 
eekly, so that
from one week to the next a different neurotransmitter would be called into action to provide the sensation of satiety I found that about eight different medications, changed every week for eight weeks, and then repeating the cycle, would perpetuate the effect for as long as people continued to take them At one point this looked to be a very promising means to help get weight off and keep it off I even acquired a patent for the technique Over time, however, I found several significant reasons not to continue pursuing this route The most insurmountable of
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
these was that it was just too difficult for most people to follow their normal regimen of diabetes medications while at the same time changing their regimen of appetite suppressants from week to week Add to that the difficulty of working with a patient over a number of weeks just to find
eight medications that worked for them and could be rotated What I did discover during all this trial and error were two effective methods of curbing overeating The results my patients have had with them are so significant that I devoted the whole next chapter to them ve Reducing Serum Insulin Levels Another group of type 2 diabetics has a common story: was never fat until after my doctor I started me on insulinUsually these people have been following high-carbohydrate diets and so must inject large doses of insulin to effect a modicum of blood sugar control Insulin, remember, is the principal fat-building hormone of the body Although a type 2 diabetic may be resistant to insulin-facilitated glucose transport from blood to tissues, that resistance doesn diminish insulin capacity for fat-building In other words, insulin can be great at making t s you fat even though it may be, for those with insulin resistance, inefficient at lowering your blood sugar Since excess insulin causes insulin resistance, the more you take, the more you need, ll and the fatter you get This is not an argument against the use of insulin; rather it supports our ll conclusion that high levels of dietary
carbohydrate– which, in turn, require large amounts of insulin– usually make blood sugar control and weight reduction impossible I have witnessed, over and over, dramatic weight loss and blood sugar improvement in people who have merely been shown how to reduce their carbohydrate intake and therefore their insulin doses Although this is contrary to common teaching, you need only visit the reader reviews of the original edition of this book to read the similar experiences of many readers Several oral insulin-sensitizing agents, which we will discuss in detail in Chapter 15, can also be valuable tools for facilitating weight loss They work by making the body tissues more sensitive s to the blood sugarlowering effect of injected or self-made insulin As it then takes less insulin to accomplish our goal of blood sugar normalization, you have less of this fat-building hormone ll circulating in your body I have patients using these medications who are not diabetic, and they work in a similar way: the body is more sensitive to insulin, so it needs to produce less, and there is, again, less of it present to build fat One may also have less of a sense of hunger, and less loss of
self-control At wwwamazoncom and wwwdiabetes-bookcom Increasing Muscle Mass The above suggests what we have been advocating all along– a low carbohydrate diet But what do you do if this plus one of the above medications does not result in significant weight loss? Another step is muscle-building exercise Chapter 14 This is of value in weight reduction for several reasons Increasing lean body weight muscle mass upgrades insulin sensitivity, enhancing glucose transport and reducing insulin requirements for blood sugar normalization Lower insulin levels facilitate loss of stored fat Chemicals produced during exercise endorphins tend to reduce appetite, as do lower serum insulin levels People who have seen results from exercise tend to invest more effort in looking even better eg, by not overeating, and perhaps
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
exercising more They know it can
be done HOW TO ESTIMATE YOUR REAL FOOD REQUIREMENTS Now suppose you have been following our low-carbohydrate diet, have been conscientiously pumping iron,and are, in effect, doing everything right What else can you do if you have not lost weight? Well, everyone has some level of caloric intake below which they will lose weight Unfortunately, the standardformulas and tables commonly used by nutritionists set forth caloric guidelines for theoretical individuals of a certain age, height, and sex, but not for real people like us The only way to find out how much food you need in order to maintain, gain, or lose weight is by experiment Here is an experimental plan that your physician may find useful This method usually works, and without counting calories Begin by setting an initial target weight and a reasonable time frame in which to achieve it Using standard tables of ideal body weight is of little value, simply because they give a very wide target range This is because some people have more muscle and bone mass for a given height than others The high end of the ideal weight for a given height on the Metropolitan Life Insurance Company table is 30 percent greater than the low
end for the same height s Instead, estimate your target weight by looking at your body in the mirror after weighing yourself It pays to do this in the presence of your health care provider, because he/she probably has more experience in estimating the weight of your body fat If you can grab handfuls of fat at the underside of your upper arms, around your thighs, around your waist, or over your belly, it is pretty clear that your body is set for the next famine Your estimate at this point need not be terribly precise, because as you lose weight your target weight can be re estimated Say, for example, that you weigh 200 pounds You and your physician may agree that a reasonable target would be 150 pounds By the time you reach 160 pounds, however, you may have lost your visible excess fat– so settle for 160 pounds Alternatively, if you still have fat around your belly when you get down to 150 pounds, it won hurt to shoot for 145 or 140 as your next target, before t making another visual evaluation Gradually you home in on your eventual target, using smaller and smaller steps Once your initial target weight has been agreed upon, a time frame for losing the weight should be established
Again, this need not be utterly precise It important, however, not to s crash diet This may cause a yo-yo effect by slowing your metabolism and making it difficult to keep off the lost bulk Bear in mind that if you starve yourself and lose 10 pounds without adequate dietary protein and an accompanying exercise regimen, you may lose 5 pounds of fat and 5 pounds of muscle If you gain back that 10 pounds from eating carbohydrate and still are not exercising, it may be all fat After crash dieting, once you reached your target, you may go right back to ve overeating I like to have my patients follow a gradual weight-reduction diet that matches as closely as possible what they probably be eating after the target has been reached In other ll words, once your weight has leveled off at your target, you stay on the same diet you followed while losing weight– provided, of course, that you don continue losing weight This way you t ve gotten into the habit of eating a certain amount, and you stick to this amount, more or less, for life To achieve this, weight loss must be gradual If you are targeted to lose 25 pounds or less, I suggest a reduction of 1 pound per week If you heavier, you may
try for 2 pounds per week If re
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
just cutting the carbohydrate results in a more rapid weight loss, don worry– just enjoy your luck t This has happened to a number of my patients Weigh yourself once weekly– stripped, if possible, on the same scale, and before breakfast Pick a convenient day, and weigh yourself on the same day each week at the same time of day It counterproductive and not very informative s to weigh yourself more often Small, normal variations in body weight occur from day to day and can be frustrating if you misinterpret them Generally speaking, you won lose or gain a pound of t body fat in a day Continue on your low-carbohydrate diet, with enough protein foods to keep you comfortable Let say that your goal is to lose 1 pound every week Weigh yourself after one week If you s ve lost the weight, don change anything If you
haven lost the pound, reduce the protein at any t t one meal by one third For example, if you been eating 6 ounces of fish or meat at dinner, cut ve it to 4 ounces You can pick which meal to cut Check your weight one week later If you have lost a pound, don change anything If you haven cut the protein at another meal by one-third If you t t, haven lost the pound in the subsequent week, cut the protein by one third in the one remaining t meal Keep doing this, week by week, until you are losing at the target rate Never add back any protein that you have cut out, even if you subsequently lose 2 or 3 pounds in a week If you managed to lose at least 1 pound weekly for many weeks but then your weight levels off, ve this is a good time for your physician to prescribe the special insulin resistancelowering agents described in Chapter 15 Alternatively you can just start cutting protein again Continue this until you reach your initial target or until your visual evaluation of excess body fat tells you that further weight loss isn necessary The average non pregnant, sedentary adult with an ideal body weight t of 150 pounds requires about 9 ounces of high-quality protein food ie, 54 grams of
pure protein daily to prevent protein malnutrition It is therefore unwise to cut your protein intake much below this level adjusted for your own ideal body weight If you exercise strenuously and regularly, you may need much more than this Once you reached your target weight, do not add back any food You will probably have to ve stay on approximately this diet for many years, but you easily become accustomed to it If you ll required one of the appetite-reducing approaches described in the next chapter, do not discontinue it
This may not work for girls or women with polycystic ovarian syndrome PCOS They may fail to lose weight even on a near-starvation diet see Appendix E
SOME FINAL NOTES Reduce Diabetes Medications While Cutting Protein or Losing Weight While you losing weight, keep checking blood sugars at least 4 times daily, at least 2 days a re week If they consistently drop below your target value for even a few days, advise your physician immediately It will probably be necessary to reduce the doses of any blood sugarlowering medications you may be taking Keeping track of your blood sugar levels as you eat less and lose weight is essential for the prevention of excessively
low blood sugars Increased Thrombotic Activity During Weight Loss During weight loss, many people unknowingly experience increased clumping of the small particles in the blood platelets that form clots thrombi This can increase the risk of heart attack
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
or stroke Your physician may therefore want you to take an 80 mg chewable aspirin once daily during a meal to reduce this tendency The aspirin should be chewed midway through a meal to reduce the possibility of irritation to the stomach or intestines Alternatively you can use vitamin E in the form of gamma tocopherol or mixed tocopherols The dosing would be 400 mg one to three times daily depending upon your size It need not be taken during meals, as it won irritate your t gastrointestinal tract Elevated Serum Triglycerides During Weight Loss When you losing weight, fat is re mobilizedfor
oxidation– ie, to be burned– and it will appear in the bloodstream as triglycerides If you see elevated serum triglyceride levels as you losing re weight, it not something to worry about Your triglyceride levels will drop as soon as weight loss s levels off Supplemental Calcium May Help There is recent evidence that calcium supplements 1,0003,000 mg daily may facilitate weight loss by inhibiting the accompanying slowdown in metabolism that may occur when you lose weight As indicated previously, I recommend calcium supplements that also contain vitamin D, magnesium, and manganese This supplement has also been used to successfully treat the dysphoric mood and carbohydrate craving in women who suffer from premenstrual syndrome
Copyright 1997, 2003 by Richard K Bernstein, MD All rights reserved No part of this book may be reproduced in any form or by any electronic or mechanical means, including information storage and retrieval systems, without permission in writing from the publisher, except by a reviewer who may quote brief passages in a review
wwwdiabetes-bookcom
Source:diabetes-normalsugars.com
