Diabetes Treatments

If you have type 2 diabetes and are overweight, it is important that weight loss out to him the likely connection between his diabetes and his obesity. …

12
Weight Loss - If Youre Overweight

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 dont 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 dont think, He ought to control
his eating I think, He has the thrifty genotype What 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 werent faced with famine The Bureau of
Indian 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

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
werent hungry, would have made more insulin and thereby stored more fat
Add to this the 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 7-10 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 flaw causes 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 cured their 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 Indians ability to survive long enough to
find food is nothing short 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

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 high-carbohydrate 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

Its clear that thrifty genotypes work in isolated populations to make
metabolism supremely energy-efficient, but what happens when the
populations have unrestricted access to high-carbohydrate 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 Shes not really hungry Shes
depressed and trying to make herself feel better Shes indulging herself,
we think, rewarding herself in a way for enduring one of lifes traumas,
and we laugh because we 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 shes hungry but because she knows, 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 doesnt make much of a
difference Its the carbohydrate that 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, shell have to inject a lot of insulin to get her blood sugar
down, with the same effect-more carbohydrate craving and building up of fat
reserves

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 youre overweight, youre probably unhappy with your appearance, and no
less with your high blood sugars Perhaps in the past youve tried to
follow a restricted diet, without success 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 dont
work for everyone

Medications

If youre a compulsive overeater, if you just cant stop yourself from
eating, and are addicted to 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
diet-proof patients 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 weekly, 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 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 Ive devoted the whole next chapter to them

Reducing Serum Insulin Levels

Another group of type 2 diabetics has a common story: I was never fat
until after my doctor started me on insulin Usually 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 doesnt diminish
insulins capacity for fat-building In other words, insulin can be great
at making 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 youll need, and the fatter
youll get This is not an argument against the use of insulin; rather it
supports our 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 bodys tissues more sensitive to the blood sugar-
lowering effect of injected or self-made insulin As it then takes less
insulin to accomplish our goal of blood sugar normalization, youll have
less of this fat-building hormone 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
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 standard formulas 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 Companys table is 30 percent greater than
the low end for the same height

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 wont hurt to shoot for 145 or 140 as your next
target, before 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 Its important, however, not to 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
youve reached your target, you may
go right back to overeating I like to
have my patients follow a gradual weight-reduction diet that matches as
closely as possible what theyll probably be eating after the target has
been reached In other 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 dont continue losing weight This way youve
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 youre
heavier, you may try for 2 pounds per week If just cutting the
carbohydrate results in a more rapid weight loss, dont worry-just enjoy
your luck 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 Its counterproductive and not very informative 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 wont lose or gain a pound of body fat in a day Continue on your low-
carbohydrate diet, with enough protein foods to keep you comfortable

Lets say that your goal is to lose 1 pound every week Weigh yourself
after one week If youve lost the weight, dont change anything If you
havent lost the pound, reduce the protein at any one meal by one third
For example, if youve been eating 6 ounces of fish or meat at dinner, cut
it to 4 ounces You can pick which meal to cut Check your weight one week
later If you have lost a pound, dont change anything If you havent, cut
the protein at another meal by one-third If you
havent lost the pound in the subsequent week, cut the protein by one third
in the one remaining 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 youve managed to lose at least 1 pound weekly for many weeks but then
your weight levels off, this is a good time for your physician to prescribe
the special insulin resistance-lowering 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 isnt necessary The average
non pregnant, sedentary adult with an ideal body weight 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 youve reached your target weight, do not add back any food You will
probably have to stay on approximately this diet for many years, but youll
easily become accustomed to it If you 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 youre losing weight, keep checking blood sugars at least 4 times
daily, at least 2 days a 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 sugar-lowering
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 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 wont irritate your gastrointestinal tract

Elevated Serum Triglycerides During Weight Loss

When youre losing weight, fat is mobilized for oxidation-ie, to be
burned-and it will appear in the
bloodstream as triglycerides If you see
elevated serum triglyceride levels as youre losing weight, its not
something to worry about Your triglyceride levels will drop as soon as
weight loss levels off

Supplemental Calcium May Help

There is recent evidence that calcium supplements 1,000-3,000 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

Source:womeningovernment.org