Losing Weight with Diabetes: What Prevents It and Causes Weight Gain

Last year I participated in a discussion on a Facebook group for athletes with diabetes about how hard it can be to lose weight through exercise. While I would never claim to have all the answers on this topic, here are some ideas about what can make you gain weight or keep you from losing weight with diabetes, based on my decades of professional and personal experience with diabetes and weight management, and what you can do about it. wirchappybiker

My former graduate student with type 1 diabetes went on an insulin pump and promptly gained about 10 pounds, even though his blood glucose control improved only marginally.  Why did this happen to him (and why does it happen to so many other insulin users)?

As a naturally occurring anabolic hormone, insulin promotes the uptake and storage of glucose, amino acids, and fat into insulin-sensitive cells around your body (mainly muscle and fat cells).  It doesn’t matter whether it’s released naturally, injected, or pumped—all insulin and insulin analogs have these same effects.  Going on intensive insulin therapy is associated with fat weight gain (1), for people with both type 1 and type 2 diabetes.  Some of the weight gain comes from that if you’re using insulin to keep your blood glucose in control, you’ll be keeping and storing all of the calories that you’re eating instead of losing some glucose through urine (during hyperglycemia).  Unfortunately, this realization has led some people to try skipping or limiting their insulin use to help them lose weight (2), but that is a dangerous practice that can lead to loss of excess muscle mass and life-threatening conditions like DKA.

The best way to balance your insulin use and your body weight, in my opinion, is to be physically active to keep your overall insulin levels lower.  It’s easier to lose weight, too, when you’re taking less insulin—or releasing less of your own if your pancreas still does that.

Food Choices

Having said that, I have to say that what you choose to eat has a huge impact on your insulin needs as well as your body weight.  My graduate student found that by doing frequent dosing with his insulin pump, he was eating more overall, just because he could without having to take another injection with a needle.  Just because insulin use can make it easier for you to eat cake and other formerly “forbidden” foods doesn’t mean that you need to eat them!

There are advocates out there for all sorts of diets for people with diabetes, including ultra-low-carb ones (like Dr. Bernstein’s), vegan ones, etc.  Personally, what I have always founds works best for weight management with diabetes is a balanced diet, nothing too extreme in any direction.  People don’t necessarily lose weight on low-carb diets, even though their insulin requirements are lower because fat is so much denser in calories (at over 9 calories/gram of fat) than carbs or protein (both 4 calories per gram).  If you cut carbs out of your diet, you have to eat something in its place.  It’s just too easy to overdose on fat calories without realizing it, and even when your muscles become insulin resistant for any reason, insulin still usually works to put fat into storage depots around the body.

My trick is not to completely avoid carbs, but rather to choose them wisely—eating more lower glycemic index, or GI, carbs that are absorbed more slowly and don’t cause spikes in blood glucose that you have to try to match with large doses of insulin that often lead to hypoglycemia later on when the carbs are long gone and the insulin is still hanging around.  Remember, most carbs are fully absorbed in the first hour or two after you eat them, and even rapid-acting insulin can linger for up to 8 hours afterward.

Besides, insulin requirements are determined by more than just carbs, as finally proven in a study in 2013 showing that eating fat with the same number of carbs increases insulin requirements (3). (I knew this through personal experience already!)  It’s not just about carb counting anymore (and never has been for me); it’s about picking the right balance and type of carbs, as well as total amounts of protein (good for preventing lows 3 to 4 hours later) and fat (fully absorbed in 5 to 6 hours, causing insulin resistance).

Treating Lows

I was contacted once by a US Olympic team handball player with type 1 diabetes who wanted to ask me why she was gaining fat weight while doing all her training.  My first question to her was, “Are you treating a lot of lows?” I knew she was going to answer yes before I even heard back from her.

This phenomenon (gaining weight from treating lows) is not uncommon in people using insulin, whether they are active or not.  One of the biggest deterrents to successful weight loss and prevention of weight gain with diabetes is being forced to treat frequent bouts of hypoglycemia with glucose, sugary drinks, or food.  Even though these calories are necessary to treat a medical condition, they still count as calories in the body, and they can result in weight gain.

One way to cut back on lows is to decrease your insulin intake to prevent them, which may include decreasing meal-time insulin doses before exercise, insulin taken for food after exercise, and basal insulin doses to prevent later-onset hypoglycemia following activities.  It also helps to more precisely treat lows instead of overtreating them (it’s harder to follow this advice when you’re low, though!) Immediately treat lows first with glucose—in the form of tablets, gels, or candy containing dextrose like Smarties)—and then reassess later if you need additional food intake (often a mix of carbs, protein, and fat) to fully correct the low and prevent lows later on.  Juice, although often touted as a treatment for hypoglycemia, contains fructose (fruit sugar) that is much, much more slowly absorbed than glucose and can lead to overtreating lows while you’re waiting for the juice to kick in.  Don’t eat more calories treating a low than you need to!

Lack of Physical Movement

Finally, and I probably should have listed this section first, expending more calories can help prevent weight gain, even if you take insulin.  In adults with type 1 diabetes, having an active lifestyle compared to a more sedentary one has been associated with a lower BMI (body mass index) and percentage of total and truncal fat mass (5).  The more you move, the less insulin your body needs to get the same glucose-lowering effect.  Requiring smaller doses of insulin allows you to 1) treat lows with fewer calories overall, and 2) avoid having as many lows from being off on your dosing.

In anyone who is insulin resistant (most people with type 2 diabetes and many with type 1 who are inactive), total insulin requirements will be so much higher that there is a lot more room for error.  Injected or pumped insulin is generally absorbed at a speed dictated by the dose, meaning that larger doses take longer to fully absorb and the insulin “tail” hangs around for longer.  Taking or releasing less insulin due to being physically active means that all of the carbs you take will be stored as carbs in muscle or liver and not converted into fat to be stored.  Stay regularly active—even if that means just standing up more or taking more daily steps–to keep your calorie expenditure high and your insulin needs low.

                                                                                                                                                           

References:

  1. Conway B, Miller RG, Costacou T, Fried L, Kelsey S, Evans RW, and Orchard TJ. Temporal patterns in overweight and obesity in Type 1 diabetes. Diabet Med 27: 398-404, 2010. (http://www.ncbi.nlm.nih.gov/pubmed/20536510)
  2. Ackard DM, Vik N, Neumark-Sztainer D, Schmitz KH, Hannan P, and Jacobs DR, Jr. Disordered eating and body dissatisfaction in adolescents with type 1 diabetes and a population-based comparison sample: comparative prevalence and clinical implications. Pediatr Diabetes 9: 312-319, 2008. (http://www.ncbi.nlm.nih.gov/pubmed/18466215)
  3. Wolpert HA, Atakov-Castillo A, Smith SA, and Steil GM. Dietary Fat Acutely Increases Glucose Concentrations and Insulin Requirements in Patients With Type 1 Diabetes: Implications for carbohydrate-based bolus dose calculation and intensive diabetes management. Diabetes care 36: 810-816, 2013. (http://www.ncbi.nlm.nih.gov/pubmed/23193216)
  4. Brown RJ, Wijewickrama RC, Harlan DM, and Rother KI. Uncoupling intensive insulin therapy from weight gain and hypoglycemia in type 1 diabetes. Diabetes Technol Ther 13: 457-460, 2011. (http://www.ncbi.nlm.nih.gov/pubmed/21355723)
  5. Brazeau AS, Leroux C, Mircescu H, and Rabasa-Lhoret R. Physical activity level and body composition among adults with type 1 diabetes. Diabet Med 29: e402-408, 2012. doi: 410.1111/j.1464-5491.2012.03757.x. (http://www.ncbi.nlm.nih.gov/pubmed/22817453)

Don’t Let Diabetes Stand in the Way of Your Dreams

Sheri and Steve at UVI (brighter)

I had to wait more than half my life to overcome the only thing I had never been allowed to do with type 1 diabetes…but I finally prevailed.

You can do almost everything you want to with diabetes.  One blaring exception is scuba diving through any NAUI (National Association of Underwater Instructors) organization.

My story is that when I was a graduate student back in 1987, I signed up at the University of California, Davis for a scuba diving certification course.  I didn’t know about NAUI or much of anything scuba-related, but got a rude awakening when I was booted out of the class after having a required physical exam and admitting that I had type 1 diabetes.  I was devastated.  Despite having had diabetes since the age of four, I had never let it stand in my way of reaching my goals (even though I didn’t have a blood glucose meter back then).

So, I went with the UC Davis scuba class to Lake Tahoe and waited lakeside while everyone else in the class got to dive.  I guess I was just a glutton for punishment!

What I didn’t know at the time was that the other primary scuba diving organization (PADI, the Professional Association of Diving Instructors) lets people with type 1 diabetes dive, and thousands of individuals with diabetes have dived safely over the years.  The Divers Alert Network (DAN) has also advised people with diabetes about staying safe while diving, and many of their recommendations are based on the extensive experience with diving with adults with type 1 diabetes amassed by Steve Prosterman, a diving instructor at the University of the Virgin Islands (who also happens to have type 1 diabetes).

I met Steve at a diabetic athletes’ meeting I attended back in 1990, and after hearing my story, he graciously invited me to come to UVI anytime to learn how to dive with him.  I waited 27 years to take him up on his offer, but I finally fulfilled my almost lifelong dream of going scuba diving–on my 50th birthday!  It was the best way I could have ever celebrated a half-century of life and almost 46 years living with type 1 diabetes.  Thank you, Steve, for helping me make my dream come true!

Sheri, 1; type 1 diabetes and NAUI, 0. Finally!!

Scott Dunton Walking

Exercise: It Does a Body Good!

Athletes around the world are now competing (and competing well) with diabetes. Scott Dunton, a professional surfer with type 1 diabetes, is just one example of how exercise does a body good!

However, there are some things I wish I had always known about exercising with diabetes…

Being active has always made me feel better, physically and emotionally.  But here are some other things about exercise that I wish someone had told me years ago.

1) Exercise can help erase your blood glucose “mistakes”

  • Exercise acts as an extra dose of insulin, figuratively.
  • At rest, insulin is the main way to get glucose into muscle cells, but during exercise, glucose goes muscles without insulin (caused by muscle contractions).
  • Being regularly active makes your muscles more sensitive to insulin, so you will need lower doses of it overall.
  • What better way to help erase a little overeating of carbs (or some insulin resistance) than a moderate dose of exercise to lower your blood glucose?

2) Exercise doesn’t always make your blood glucose go down

  • It doesn’t always make your blood glucose come down, at least not right away.
  • During intense exercise, the glucose-raising hormones your body releases can raise your blood glucose (think high-intensity interval training).
  • Over a longer period of time (2-3 hours), it usually comes back down.
  • If you take insulin, take less than normal to correct a post-workout high or your blood glucose will likely be crashing low a few hours later.
  • A cool-down of less intense exercise (like walking) can help bring it back to normal, though.

3) Your muscle mass is critical to managing blood glucose levels

  • Exercise helps you build and retain your muscle mass, and muscles are the main place you store carbs after you eat them—like a gas tank.
  • Exercising helps use up stored carbs, but can also increase the size of the tank.
  • When you eat carbs post-exercise, they can easily go into storage with a little insulin (or sometimes none at all).
  • Being sedentary keeps the tank full and makes you resistant to insulin.
  • Aging alone can cause you to lose muscle mass over time.
  • Resistance training and/or high-intensity intervals build muscle more, so you need to include these activities regularly as part of your workouts.

4) It’s the best medicine there is

  • Control stress and stave off depression with exercise—and it has no bad side-effects!
  • Exercise is a natural antioxidant—better than supplements!
  • Being active prevents all sorts of cancers, including prostate and breast.
  • It will help you feel better and look younger than you are (and we can all use help with that).
  • You’ll be even less likely to catch a cold, if you exercise moderately.
  • Don’t forget your daily dose of exercise “medicine”
  • Standing more, taking extra steps, and fidgeting help–just be active all day long any way that you can!

Diabetes Motion: Practical advice about exercise and fatigue solutions

Whether you’rDiabetes Motione new to exercise or a sports enthusiast, diabetes can get in the way of being physically active. To deal with this problem, I founded a new information web site called Diabetes Motion (www.diabetesmotion.com), given that I’m one of the world’s leading experts on diabetes and exercise. The mission of Diabetes Motion is to provide practical guidance about blood glucose management to anyone who wants to be physically active with diabetes.

Without a doubt, being physically active is good for the body, heart, and mind. If you are already an avid exerciser, then you know the benefits of exercise for your health and diabetes control. If you are just thinking about getting serious about sports or fitness activities, then you have a lot of positive changes to look forward to.

Exercise can help you build muscle and lose body fat, suppress your appetite, eat more without gaining fat weight, enhance your mood, reduce stress and anxiety, increase your energy, bolster your immune system, keep your joints and muscles more flexible, and improve the quality of your life. For many people with diabetes, being physically active has made all the difference between controlling diabetes or letting it control them.

What you may not know is what type of exercise or physical activity you should you be doing or how much of it is recommended for optimal health and the best blood glucose control. The good news is that you can get different (but all good) benefits from doing a variety of types of daily movement, which gives you a lot of options. In fact, exercising regularly is likely the single most important thing you can do to slow the aging process, manage your blood sugars, and reduce your risk of diabetic complications.

Need help with revving up your exercise? If your exercise performance been less than you’d hoped recently, here are some potential causes of fatigue (and solutions):

Inadequate rest time: You may be getting through your workouts well, but then fail to perform when you have races and events simply because you didn’t take enough rest time to restore glycogen and fully recover. It’s critical to cut back on your workouts (“taper”) for at least 1-2 days before a big event and keep your blood glucose in good control so your glycogen levels will be as full as possible on race/event day.

Blood glucose and glycogen stores: It’s harder for your body to restore your muscle glycogen (stored carbs) between workouts unless you’re eating enough carbs and have functioning insulin available. Your carb intake doesn’t have to be tremendous—probably just 40% of your total calories coming from carbs will suffice—but your blood glucose absolutely needs to be in good control for your muscles to restore carbs optimally.

Iron: Having low iron stores can cause you to feel tired all the time, colder than normal, and just generally lackluster. You can get a simple blood test done to check your hemoglobin (iron in red blood cells) and your overall iron status (serum ferritins). If your body’s iron levels are low (due to diabetes or non-diabetes causes), taking iron supplements can help, along with eating more red meat with lots of absorbable iron.

Magnesium: You may have a magnesium deficiency, especially if you take insulin or your blood glucose levels are not optimal. Magnesium is involved in over 300 metabolic pathways. If you’re deficient, your exercise will be compromised and you may even experience some muscle cramping. To correct a deficiency, eat more foods with magnesium in them—such as nuts and seeds, dark leafy greens, legumes, oats, fish, and even dark chocolate—but taking a supplement may also help.

B vitamins: For people with diabetes, thiamin (vitamin B1) deficiency is also a likely culprit in exercisers and can be further depleted by alcohol intake. People who take metformin to control diabetes can also end up deficient in vitamins B6 and B12, both of which are essential to exercising well. Consider taking a vitamin B complex daily.

Thyroid issues: Having lower levels of functioning thyroid hormones can cause fatigue and poor exercise performance. Have your main thyroid hormones (TSH, T3 and T4), but possibly also your thyroid antibodies if your thyroid hormones levels are normal and nothing else is helping your exercise (specifically antibodies to thyroid peroxidase), especially if you have celiac disease.

Still stumped? If you’ve been through this list and had everything check out okay, then consider other possible issues like your hydration status, daily carb intake (adding even just 50 grams per day to your diet may help), other possible vitamin and mineral deficiencies (vitamin D, potassium, etc.), statin use (some statins taken to lower blood cholesterol cause unexplained muscle fatigue), and frequent hypoglycemia.

Please visit www.diabetesmotion.com for more helpful information about being active with diabetes.

Should You Just Do Intense Exercise for Less Time?

Just when everyone was already confused about what types and amounts of training people with diabetes should be doing, along comes yet another study to muddy the waters some more. This latest exercise research was undertaken by faculty at McMaster University in Hamilton, Ontario, and appeared in the December 2011 issue of Journal of Applied Physiology (1).

The study involved eight individuals with type 2 diabetes (mean age of 63 years) who agreed to endure six sessions of high-intensity interval training done on a cycle ergometer over a two-week period. The training sessions consisted of 60 seconds of cycling done 10 times at ~90% of maximal heart rate, interspersed with 60 seconds of rest—for a total of only 10 minutes of actual exercise and 10 minutes of recovery. In other words, it involved almost an all-out sprint for a minute at a time, repeated 10 times with very little rest in between. Some call this low-volume, high-intensity interval training (HIT); others call it pure torture.

Before training and from ∼48 to 72 h after the last training bout, blood glucose responses were monitored using 24-hour continuous glucose monitoring. The exercise definitely had a positive effect on blood glucose levels: both the average levels over 24 hours and the 3-hour postprandial values after all three daily meals were improved significantly even 2-3 days after each training session, suggesting that low-volume HIT can rapidly improve glucose control and induce adaptations in skeletal muscle that improve metabolic health in people with type 2 diabetes.

While interval training is routinely used by sports teams and athletes, I have to question whether doing only this type of training would be beneficial for most individuals with diabetes. It certainly saves time—who can’t fit in 10 minutes of exercise three days per week?—but would it benefit weight control in the average person with type 2 diabetes? Probably not, as it simply doesn’t burn that many calories. Actually, it doesn’t save that much time either: when you add in the interspersed rest intervals and a warm-up and cool-down period, it still takes at least 25 minutes per session and 75 minutes per week. Current recs from the American Diabetes Association suggest that people with diabetes should try to get at least 150 minutes of moderate to vigorous exercise each week—an average of 30 minutes a day if done five days a week—so you’d only really be saving time on the two extra days you’re not doing the HIT routine.

There is no doubt that doing HIT training does have some benefits. This research suggests that doing thrice-weekly short intensive workouts may help lower blood sugar levels similarly to more frequently performed moderate activities. The sessions themselves dropped blood sugar levels from 137 mg/dL to 119 mg/dL, on average, which isn’t bad for only 10 minutes of exercise. In addition, overall and post-meal blood sugar levels were reduced long after training sessions were completed, which may or may not happen with more moderate workouts.

On the flip side, others who wrote articles about this training regimen also commented that “it requires so much suffering that you’re almost destined to quit.” Unless it’s regularly done with others, a coach, or a personal trainer to ensure motivation and positive feedback, most individuals will not have the drive to continue doing this type of training on their own long-term. What’s more, doing really intense exercise can actually cause a short-term elevation in blood glucose instead of a decrease, especially if the intense activity is not repeated enough times (such as the 10 sessions in this study) due to the effects of glucose-raising hormones released by sprinting. (So, you probably couldn’t stop early and gain the same benefits.)

If you can only do five to 10 minutes of exercise, that’s certainly better than nothing, but you really start to see the effects of exercise if you can regularly exercise harder and longer—for 20 to 30 minutes at least a few times a week. Another drawback of doing low-volume HIT is simply that not everyone is going to be able to do it, and it’s certainly not the best routine to start with when you’ve been sedentary for a while. It’s also more likely to result in overuse injuries and other joint problems that will stop you from doing anything after a while.

However, I’m totally in favor of routinely interspersing harder intervals into any regular training session—regardless of how easy or hard it is—both to increase cardiovascular fitness and to use up more blood glucose and stored carbohydrate (glycogen) in muscles, just like was done in one pilot study a few years back (2). Starting with easier workouts and interspersing slightly harder intervals into them is a lot more realistic for the majority of folks out there just getting started.

The bottom line: Just get up and off the couch to do any type of physical activity regularly, and your blood glucose levels will thank you.

References Cited:

(1) Little JP, Gillen JB, Percival ME, Safdar A, Tarnopolsky MA, Punthakee Z, Jung ME, Gibala MJ. Low-volume high-intensity interval training reduces hyperglycemia and increases muscle mitochondrial capacity in patients with type 2 diabetes. J Appl Physiol. 2006;111(6):1554-60.

(2) Johnson ST, McCargar LJ, Bell GJ, Tudor-Locke C, Harber VJ, Bell RC. Walking faster:  distilling a complex prescription for type 2 diabetes management through pedometry. Diabetes Care 2006;29:1654-5.

Taking Insulin? Avoid Getting Fat!

A lot of people with type 2 diabetes delay going on insulin for as long as possible because they’ve heard horror stories about how much weight it can make them gain (or maybe they just don’t like shots), but people with type 1 don’t have a choice.  While it is true that insulin treatment is often associated with weight gain and more frequent bouts of hypoglycemia (low blood sugar), the real question is, why?

Some theories to explain insulin-induced weight gain are that when using insulin, your blood sugar is (usually) better controlled and you stop losing some of your calories (as glucose in your urine when your blood sugars exceed your urinary threshold) and that you may gain weight from having to eat extra to treat any low blood sugars caused by insulin. If you’re taking oral medications to lower your blood sugar and they are not working, however, insulin may be your main option for better control.

A few research studies have looked at whether weight gain is simply a result of eating more when you’re on insulin. One such study found that weight gain was not due to an increase in food intake, but rather that your body may increase its efficiency in using glucose and other fuels when your glycemic control improves—making you store more available energy from the foods you eat as fat (even if you’re eating the same amount as before you went on insulin) (1).  

So, what can you do to avoid weight gain if you have to take insulin?  First of all, you should try to keep your insulin doses as low as possible because the more insulin you take, the greater your potential for weight gain is.  The best way to keep your insulin needs in check is to engage in regular physical activity.  By way of example, some people with type 2 diabetes who were studied gained weight from insulin use while others did not.  Interestingly, the main difference between the “gainers” and the “non-gainers” was that the gainers were less physically active (2). Moreover, in people with type 1 diabetes, taking insulin doses that effectively manage blood sugars can also lead to weight gain, but increases in activity levels have been shown to prevent getting fatter (3).

During any physical activity, your muscles can take up blood glucose and use it as a fuel without insulin and then following exercise, your insulin action is heightened for a few hours and as long as 72 hours—meaning that you will need smaller doses of insulin to have the same glucose-lowering effect.  It is my personal experience that regular exercise is the best way to prevent insulin-induced weight gain, but your insulin doses will also need to be adjusted downward to prevent low blood sugars that cause you to take in extra calories to treat them.

Second, you may be able to avoid weight gain by taking a look at the type of insulin(s) that you are using.  For example, in overweight type 2 diabetic subjects, use of once-daily Levemir (detemir) caused less weight gain and less frequent hypoglycemia than use of NPH (4), even combined with use of rapid-acting injections of a separate insulin for meals (and the same is likely true when using Lantus, or insulin glargine).  Anyone taking basal insulin alone (once or twice daily) or following a basal-bolus regimen can benefit by making sure that insulin doses are regulated effectively to prevent blood sugar lows and highs—while using as little insulin as absolutely necessary to get the desired glycemic effect.

In other words, the type of insulin you use and the doses you take are both important to consider in the overall management of your diabetes and your body weight, regardless of which type you have. Just as importantly, though, is how you choose to manage your lifestyle, both your exercise and your dietary choices.  Changes in your lifestyle, such as cutting back on refined carbohydrates that require larger doses of insulin to cover them and exercising regularly, are likely your best bets to counteract any potential weight gain caused by insulin use.  An added side benefit is that if you have type 2 diabetes and start exercising regularly, you may actually lose fat weight and be able to lower your insulin doses more or get off of insulin injections completely.

References cited:

  1. Jacob AN et al. Weight gain in type 2 diabetes mellitus. Diabetes Obes Metab. 2007 May;9(3):386-93.
  2. Jansen HJ et al. Pronounced weight gain in insulin-treated patients with type 2 diabetes mellitus is associated with an unfavourable cardiometabolic risk profile. Neth J Med. 2010 Nov;68(11):359-66.
  3. Jacob AN et al. Potential causes of weight gain in type 1 diabetes mellitus. Diabetes Obes Metab. 2006 Jul;8(4):404-11.
  4. Fajardo Montañana C  et al. Less weight gain and hypoglycaemia with once-daily insulin detemir than NPH insulin in intensification of insulin therapy in overweight Type 2 diabetes patients: the PREDICTIVE BMI clinical trial. Diabet Med. 2008 Aug;25(8):916-23.

Why Everyone Is Getting Diabetes (and Prediabetes)

The latest statistics about diabetes released by the Centers for Disease Control and Prevention are staggering: 25.8 million Americans have diabetes, and another 79 million with prediabetes are waiting in the wings to develop it. This rise in cases is exponentially greater than what was predicted even a decade ago, and the increase in diabetes a worldwide trend, not just a North American one. At current rates, everyone around the globe will have diabetes or prediabetes before the end of this century.

People are quick to point their fingers at weight gain, fast food gluttony, and slothful lifestyles as being the main culprits, but what if it’s more than that? Is there anything that can be done to abate this looming health crisis? In his recent book, Diabetes Rising, author and journalist Dan Hurley examines five potential reasons behind what has become a modern pandemic. At this point, his five hypotheses—revolving around weight gain, cow’s milk, persistent organic pollutants (POP), vitamin D, and hygiene—warrant further discussion.

The first is the Accelerator Hypothesis, which revolves around body weight and insulin resistance. Some researchers are actually beginning to believe that type 1 and type 2 diabetes–heretofore considered to be caused by autoimmune destruction of insulin-producing beta cells and a high level of insulin resistance, respectively–may actually be the same disease. He postulates that the recent rise in cases of both types of diabetes have been accelerated by weight gain (an environmental factor), but are modulated by genetic factors, including the tendency to have a highly reactive immune system and the tendency to develop insulin resistance in response to weight gain. The jury is still out on whether weight gain is a direct casual factor, but we do know that type 2 diabetes risk can be lowered greatly by even a small (5-7%) decrease in body weight.

The Cow’s Milk Hypothesis relates more directly to the development of type 1 diabetes and could more accurately be called the Foreign Protein one. In essence, early exposure in infancy to any proteins other than the ones found in human breast milk appears to make the body’s immune system more permissive toward autoimmunity and the ultimate destruction of the insulin-producing beta cells in the pancreas. An easy (and economical) approach is to promote the breast feeding of all infants as long as possible during the first year of life.

Hurley’s discussion of the risks associated with organic pollutants in the POP Hypothesis is quite compelling and is picking up steam. POPs originate from pesticides, but also from solvents, pharmaceuticals, paints, pollution, and even plastic. These compounds accumulate in body fat, so levels are higher farther up the food chain. One study actually showed a 38-fold increase in diabetes incidence when comparing the lowest and highest quartiles of POP exposure, and a follow-up study suggested that obesity leads to diabetes only when a person has POPs above a certain level—which are stored in body fat. In that case, keeping body fat lower may actually be quite effective in lowering diabetes risk by decreasing the amount of POPs stored in the body.

The Sunshine Hypothesis is not a new one where type 1 diabetes is concerned as it was noted several decades ago that its incidence is higher at northern latitudes compared to southern ones. However, the role of the sun (and vitamin D) in type 2 diabetes development (and even in prediabetes) is a more recent hypothesis. Most vitamin D is manufactured in the body following exposure to sunlight, and the rise in diabetes parallels greater use of sunscreen and less time spent outdoors. The evidence is compelling enough that recommended vitamin D intakes were recently raised for the population as a whole, based on age: 600 International Units (IU) daily for children and adults up to 70 years old, 800 IU a day for ages 71 and older.

Finally, the Hygiene Hypothesis suggests that making our environments too sterile may actually be increasing our risk of developing diabetes. In fact, people living in lesser developed regions around the world have a lower incidence of type 1 diabetes, allergies, and asthma. Exposure to some bacteria and other germs appears to strengthen the immune system and keep it less likely to start attacking parts of the body.

While these theories are interesting, what we really need to know is how to reverse the potential tsunami of diabetes cases while there is still time. Hurley postulates on “curing” diabetes with an artificial pancreas and with bariatric surgery, but neither of these solutions is really a cure, nor is either feasible on a worldwide scale.

At this point in time, the ultimate key to ending the diabetes pandemic is prevention, and that “cure” is only going to come through united action to make living healthier. Collectively, we are going to have to make personal choices to eat healthier foods and demand access to healthier (and less caloric) fare; make physical movement a requirement rather than an option (in schools and in the workplace); find government-directed ways to reduce our exposure to environmental pollutants of all types; stop oversterilizing our personal environments; and spend a little more time in the sun without overdoing the sunscreen. Furthermore, it’s likely going to take community uprisings and the use of political clout to change some of the policies in place. Time to get busy!