6) CONTROLLING WEIGHT
a) Introduction
By losing weight (or more correctly, by losing adipose tissue), the insulin resistance of the typical type 2 diabetic is considerably reduced, and insulin resistance is the major small blood vessel disease problem with most type 2 diabetes. Weight reduction also prevents the heart disease that invariably accompanies type 2 diabetes. There are thousands of individuals with type 2 diabetes (and its attendant heart disease) who have successfully lost weight and kept it off with a whole host of diets and who are much healthier because of the weight loss alone. We know, "diet" is now considered a dirty four letter word and the proper politically correct term is "lifestye change". Whatever, "a rose is still a rose". The important point is that weight must be reduced to at least "normal" for most individuals with type 2 diabetes, and preferably the weight should be reduced to "low normal". The exact method of weight loss is relatively unimportant, just so long as the weight loss is maintained. For individuals with type 2 diabetes there is a caveat that the weight loss program should keep the amount of refined carbohydrates and saturated fats eaten minimized, but most weight loss diets do exactly that. An Associated Press article of March 17, 2009 says:
"Being obese can take years off your life and in some cases may be as dangerous as smoking, a new study says. British researchers at the University of Oxford analyzed 57 studies mostly in Europe and North America, following nearly one million people for an average of 10 to 15 years. During that time, about 100,000 of those people died. The studies used Body Mass Index (BMI), a measurement that divides a person's weight in kilograms by their height squared in meters to determine obesity. Researchers found that death rates were lowest in people who had a BMI of 23 to 24, on the high side of the normal range.
Health officials generally define overweight people as those with a BMI from 25 to 29, and obese people as those with a BMI above 30. The study was published online Wednesday in the medical journal, Lancet. It was paid for by Britain's Medical Research Council, the British Heart Foundation, Cancer Research UK and others. "If you are heading towards obesity, it may be a good idea to lose weight," said Sir Richard Peto, the study's main statistician and a professor at Oxford University. Peto and colleagues found that people who were moderately fat, with a BMI from 30 to 35, lost about three years of life. People who were morbidly fat — those with a BMI above 40 — lost about 10 years off their expected lifespan, similar to the effect of lifelong smoking.
Moderately obese people were 50 percent more likely to die prematurely than normal-weight people, said Gary Whitlock, the Oxford University epidemiologist who led the study. He said that obese people were also two thirds more likely to die of a heart attack or stroke, and up to four times more likely to die of diabetes, kidney or liver problems. They were one sixth more likely to die of cancer. "This really emphasizes the importance of weight gain," said Dr. Arne Astrup, a professor of nutrition at the University of Copenhagen who was not linked to the Lancet study. "Even a small increase in your BMI is enough to increase your risks for cardiovascular disease and cancer."
This study was done on normal people. The data showed that individuals with type 2 diabetes can reduce their death rate by a huge 75% by losing weight. This is not a trivial amount to be ignored! There is simply no easy way to change the data, a person with type 2 diabetes must lose weight, lots of weight. Note that there is one large confounding factor which might explain why the study above showed that "normal" and "below normal" weight individuals die at a higher rate than "slightly above normal" individuals. Alcoholics, addicts, and smokers tend to have low weights. And smokers, alcoholics and addicts die at a lower age than non-drinking non-addicted non-smokers.
The other research that supports this position on the dangers inherent in being overweight include:
1. Lipscombe LL, Hux JE. Trends in diabetes prevalence, incidence, and mortality in Ontario, Canada 1995–2005: a population-based study. Lancet 2007;369:750-6. [PubMed].
2. Déspres JP, Lemieux I. Abdominal obesity and metabolic syndrome. Nature 2006;444:881-7. [PubMed].
3. Lau DC, Douketis JD, Morrison KM, et al; Obesity Canada Clinical Practice Guidelines Expert Panel. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176:S1-13. [PubMed].
4. Haffner SM. Relationship of metabolic risk factors and development of cardiovascular disease and diabetes. Obesity (Silver Spring) 2006;14(Suppl 3):121S-7S. [PubMed].
5. Ray J, Mohllajee AP, van Dam RM, et al. Breast size and risk of type 2 diabetes. CMAJ 2008;3:289-95.
6. Hotamisligil GS. Inflammation and metabolic disorders. Nature 2006;444:860-7. [PubMed].
7. Hegele RA, Joy TR, Al-Attar SA, et al. Lipodystrophies: windows on adipose tissue biology and metabolism. J Lipid Res 2007;48:1433-44. [PubMed].
8. Danforth E Jr. Failure of adipocyte differentiation causes type II diabetes mellitus? Nature Genet 2000;26:13. [PubMed].
9. Heilbronn L, Smith SR, Ravussin E. Failure of fat cell proliferation, mitochondrial function and fat oxidation results in ectopic fat storage, insulin resistance and type 2 diabetes mellitus. Int J Obes 2004;28:S12-21.
10. Meigs JB, Wilson PWF, Fox CS, et al. Body mass index, metabolic syndrome, and risk of type 2 diabetes or cardiovascular disease. J Clin Endocrinol Metab 2006;91:2906-12. [PubMed].
11. Adrianne C. Feldstein et al. Weight change in diabetes and glycemic and blood pressure control, Diabetes Care 31:1960–1965, 2008
12. K.A. McAuley et al. Long-term effects of popular dietary approaches on weight loss and features of insulin resistance, Int J Obes 30:342–349, 2006.
13. F. Thomas et al. Cardiovascular mortality in overweight subjects: the key role of associated risk factors, Hypertension 466:654–659, 2005.
14. Tanne D, Medalie JH, Goldbourt U: Body fat distribution and long-term risk of stroke mortality. Stroke 36:1021-1025, 2005
15. Buchwald H, Avidor Y, Braunwald E, et al.: Bariatric surgery: a systematic review and meta-analysis. JAMA 292:1724-1737, 2004.
16. Katzmarzyk PT, Church TS, Janssen I, et al.: Metabolic syndrome, obesity, and mortality: Impact of cardiorespiratory fitness. Diabetes Care 28:391-397, 2005.
17. Visscher TL, Rissanen A, Seidell JC, et al.: Obesity and unhealthy life-years in adult Finns: An empirical approach. Arch Intern Med 164:1413-1420, 2004.
18. Reynolds et al., The Impact of Obesity on Active Life Expectancy in Older American Men and Women, Gerontologist 2005;45:438-444.
19. Flegal et al., Excess Deaths Associated With Underweight, Overweight, and Obesity, JAMA 2005;293:1861-1867.
20. Gregg et al., Secular Trends in Cardiovascular Disease Risk Factors According to Body Mass Index in US Adults, JAMA 2005;293:1868-1874.
21. Centers For Disease Control and Prevention, Prevalence of overweight and obesity among adults with diagnosed diabetes, MMWR Morb Mortal Wkly Rep 53:1066-1068, 2004
22, Anderson JW et al Importance of weight management in type 2 diabetes: review with meta-analysis of clinical studies, J. Am. Coll Nutr 22:331-339, 2003
23, Hensrud DD, Weight loss and maintenance in type 2 diabetes Obes res (Suppl 4):3485-3535, 2001Losing weight all sounds very simple but the reality of it is that it is very difficult and rarely successful in the long term. Most patients with type 2 diabetes need to lose 20% to 40% of their body weight to get to their low normal range. In a study of the effects of four different popular weight loss diets on obese patients for one year, over 40% dropped out! (Dansinger MG, Gleason JA, Griffith JL, et al.: Comparisons of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: A randomized trial. JAMA 293:43-50, 2005). Of the people who stayed in the four programs for the full year, only 10% lost 10% of their weight. This dispite education on the severity of the long term health problems inherent in obesity. Not a huge success story but a common theme which runs through diet studies. As you read the studies you get used to phrases such as "after a year the study participants had lost an average of 8 pounds". As Oprah's diet plans emphasis, the most successful diet plans combine strenuous exercise with diet. Strenuous exercise seems to counterintuitively reduce appetite in addition to burning more calories. But most successful diet plans emphasize exercise. It has to noted that Oprah's website has been up for many years and yet this very strong willed, extremely intelligent and very rich woman seems to be incapable of keeping the weight off. She takes it off, puts it back on, takes it off, puts it back on..... But then Oprah doesn't have the serious disease of diabetes to motivate her. Unfortunately most people with type 2 diabetes are genetically programmed to be unable to lose weight. It is not a matter of will power, it is a matter of genes and hormones. It should not be considered a personal failure when someone with type 2 diabetes cannot lose weight.
Men, for once, have an advantage when it comes to losing weight. Men might die at an earlier age than women and men are far more likely to have metabolic syndrome X. But, because of their hormones, men can more easily lose weight and tend to keep it off more easily than women. Studies show that smokers who try to stop smoking only succeed 3% of the time. Dieters who try to lose weight only succeed slightly less than 2% of the time. These are pretty dismal numbers. The key to successfully losing weight appears to be to make weight control only a small portion of a much larger permanent life style change, for instance changing the diet completely and religiously exercising one hour every single day. And avoiding the "slippery slopes" such as the traditional Friday night out at the local pizzaria. This goes counter to the recommendations of organizations such as the American Dietitic Association, who opt for only minor changes. But the recommendations are right in line with Oprahs well paid trainers and right in line with the thinking of most of the diet "gurus". Overeating is an addiction, just like smoking and alcoholism. And smokers aren't counseled to have one smoke a day and alcoholics aren't counseled to have one drink a day.
We don't believe in coddling or pulling punches when it comes to type 2 diabetes. We realize that there are movements to legitimize obesity. Indeed, many feel the very term "obese" is politically incorrect. The concept is that "this is the way I am and I'm proud of it" or "big is beautiful". There are even those who fervently believe that obesity does not contribute to diabetes. Once again, this is one claim I can find absolutely no meaningful statistically significant research to support and a lot of meaningful statistically valid research which proves it to be false (see list above). It is extremely difficult to lose weight if one is genetically programmed with the thrifty genes so the movement is understandable. "Overweight" is defined as a body mass index of between 25 and 30 (for more information on BODY Mass Index or BMI see the NIH website). Some "experts" opinion that 33% of people with type 2 diabetes are not "overweight", which simply isn't true. From the Study done by the National Centers for Disease Control (21 above) the prevalence of overweight or obesity was 85.2% in all adults with any form of diabetes, and the prevalence of obesity was 54.8%. Now of the adult populations with any form of diabetes about 10% are people with early onset type 2 diabetes and 10% are people with late onset type 1 diabetes (LADA with no insulin resistance), two diseases considerably different than insulin resistant type 2 diabetes. Both types of type 1 diabetes are characterized by low to normal weight. Using these figures almost everyone with insulin resistant type 2 diabetes will be at least "overweight". Most of the 30.4% who are overweight but not obese are probably people with type 2 diabetes who, while technically not "obese", are "overweight", have "pot bellies" and metabolic syndrome. These people still need to lose significant amounts of weight in order to take off the pot bellies. Those women who do not store fat in the belly have more leeway in what their body mass index needs to be. In type 2 diabetes it is important where the fat is located. The only individuals I know of who have type 2 diabetes and are not overweight are those individuals who were able to reduce their weight from the overweight or obese category to the normal category after diagnosis. And to a person their type 2 diabetes has come under much closer control (hasn't been cured, just controlled)
The bottom line is that excess weight for someone with type 2 diabetes is not about appearance, it is about a life and death situation. A morbidly obese person with type 2 diabetes has to lose weight in order to have a good quality of life and a long life expectancy. The results of stomach reduction surgeries have born this immutable truth out (note that there are side effects that make stomach reduction surgeries the option of last resort and sometimes even stomach reductions don't work to reduce weight). Make no mistake about it, obese people with type 2 diabetes will have serious health problems if they don't lose weight, a lot of weight. If you are reading this, chances are you have type 2 diabetes, are obese and you need to lose a lot of weight. So keep trying different diets and different exercise programs until you find ones you can make work. Do not give up! It is also important to try and lose weight as soon as one is diagnosed. The later one waits before losing weight the less effective the weight loss becomes. When type 2 diabetes becomes really severe, requiring insulin injections, diet control becomes more important. Having said all that, it must be understood that even severe dieting and vigorous exercise will only control, not cure, the disease of type 2 diabetes in the large majority of the population. And then there will always be an unfortunate small subset whose genes are such that the rapid progression of the disease is inevitable and nothing can be done.
When the beta cells in the pancreas have died off to the point that insulin injections are required, it is true that blood sugar control becomes more important to "quality of life" issues than weight reduction. But let's not forget that 75% of people with type 2 diabetes die from heart related issues. And the heart is more affected by obesity than it is by high blood sugar. So it is misleading to say that blood sugar (blood glucose) control becomes paramount and weight control becomes unimportant. There is also the argument that weight induced insulin resistance becomes less important as a factor when a person has to start taking insulin, they will just require more insulin. But this argument ignores the fact that blood sugar control becomes much easier the less the amount of insulin that is required to be injected. So insulin resistance (i.e. weight control) is still important when taking insulin during type 2 diabetes.
Diabetes and heart disease both suffer from the "way off in the future" problem. Studies have shown that people engage in risky sexual behavior even with HIV and AIDS around because the serious consequences of HIV typically don't become apparent until ten or more years after infection. The same is true of alcohol and smoking. The same is also true of heart disease and diabetes, it is possible to go years with no serious side affects even though one remains sedentary and obese. The problem comes when the day of reckoning finally arrives. When the symptoms of diabetes and heart disease do begin to have serious affects, it is often too late to reverse the damage. All the exercise and weight loss in the world won't save the patient.
Current Chapter: 6) CONTROLLING WEIGHT
a) Introduction
b) What is "Overweight"
c) The Endless Cycles of an Overweight Person with Type 2 Diabetes
d) Food and Diet
e) Food "Rules"
f) USDA Food Pyramid
g) Adaptive Human Body
h) Timing of Meals
i) Serving Size
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