Category Archives: Weight Management/Loss

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

Scale weight 2Last year I was included in a discussion on a Facebook group for athletes with diabetes about how hard it can be to lose weight through exercise. While I don’t 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.

Insulin: 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 does it happen to so many insulin users? As an 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. Going on insulin therapy is associated with fat weight gain (1), for people with both type 1 and type 2 diabetes. When you lower blood glucose with insulin, you keep and store all of the calories instead of losing some glucose through urine (during hyperglycemia). Unfortunately, some people skip or limit 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: 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 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 found works best is a balanced diet. 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 works to put fat into storage depots around the body. Don’t completely avoid carbs; rather, choose them wisely—eating more 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. 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, and eating fat with the same number of carbs increases insulin requirements (3). 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. Gaining weight from treating lows is common 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. 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 with 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)

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How to Be the Biggest Maintainer, Not Just the Biggest Loser

Biggest maintainer

A study in Obesity in May 2016 (1) reported very discouraging findings for a group of participants who had lost weight on “The Biggest Loser” (TBL) reality TV show: not only did almost all of them regain a significant amount of weight over the 6-year period afterwards, but they also had lower resting metabolic rates than expected for their body weights, even six years later. With media spin, it won’t be a surprise if everyone just gives up staying thinner and blames excess weight on a faulty, and unchangeable, metabolism.

However, there are a number of factors that impact body weight and weight regain after loss, not just resting metabolism. How much physical activity people do daily and what type, the types of food that people eat, how many calories they actually ingest daily and when they consume them, stress management, and sleep patterns also have an impact on weight maintenance and regain after loss, among other things.

My issues with this study and with TBL’s approach to weight loss are the following:

(1) The way the contestants go about losing large amounts of body weight in a relatively short time is not sustainable as a lifestyle to maintain body weight after loss;

(2) Although TBL participants exercise (a whole lot) during their initial, six-month weight loss period—which helps prevent even greater losses of lean body mass than they would experience otherwise with such extreme weight loss—it does not prevent all muscle mass loss, which means that their total amount of muscle decreased (regardless of their relative ratios of fat and non-fat tissues);

(3) Dietary changes are as important to weight management as they are to weight loss, and diet is de-emphasized on TBL, with a focus instead on reality-TV- and entertainment-driven crazy amounts and types of physical activity; and

(4) TBL approach is not the same as that reported by successful losers and maintainers followed in the National Weight Control Registry (http://www.nwcr.ws).

With regard to that last point, much can be learned from studying members of the National Weight Control Registry (NWCR), which only includes people with medically documented weight losses of at least 30 pounds that were maintained for at least a year. While the members lost and keep the weight off in a variety of ways, most report continuing to maintain a low-calorie, low-fat diet and doing high levels of physical activity. Among the NWCR members: 78% eat breakfast every day; 75% weigh themselves at least once a week; 62% watch less than 10 hours of TV per week; and 90% exercise, on average, about 1 hour per day.

In one study, NWCR subjects spent significantly more time per day in sustained bouts of moderate-to-vigorous physical activity than their overweight counterparts (41.5 ± 35.1 min/day vs. 19.2 ± 18.6 min/day) and marginally more than normal weight adults (25.8 ± 23.4), so they were actually getting more daily exercise than most (2). A 10-year study of self-reported weight loss and behavior change in 2,886 NWCR participants (78% female; mean age 48 years), and more than 87% were still maintaining at least a 10% weight loss after five and ten years (3). Even though decreases in leisure-time physical activity, dietary restraint, and frequency of self-weighing, along with increases in percentage of energy intake from fat and disinhibition, were associated with greater weight regain, the majority of weight lost by NWCR members has been maintained over 10 years.

Others have reported that the differences in total weight gain in people being overfed similar amounts of calories was likely due to the total amount of daily movement that they engaged in, including standing, fidgeting, and taking more steps, not just planned exercise (4). Weight maintenance may, therefore, as influenced by total daily activity that is not necessarily reported or measured like most moderate and vigorous exercise is.

Weight maintenance may also be as simple as staying on top of body weight. NWCR studies have shown that consistent self-weighing may help individuals maintain their successful weight loss by allowing them to catch weight gains before they escalate and make behavior changes to prevent additional weight gain, and decreased self-weighing frequency is independently associated with greater weight regain (5).

Clearly, the body is a complex system with many different bodily and environmental factors adding to the mix. In the TBL study, there was no indication that they controlled for the potential effects of the last bout of exercise on resting metabolic measures (at least this was not reported on in the study), although exercise can impact metabolism for 2-72 hours afterwards They did not measure or report on the types of foods that the “biggest losers” were eating, although fiber is known to improve the gut microbiota and may be related to successful weight loss and maintenance (7). While many reported being active, doing cardio training versus resistance can have differing impacts on muscle glycogen storage, muscle mass, and insulin action, as well as resting metabolism, and the type of activity done was not reported in TBL study.

So, before we jump to any conclusions and blame all weight regain on something completely outside our control (a lower resting metabolism) and relinquish all personal responsibility for weight maintenance, make sure to consider all of the other potentially confounding variables that have not necessarily been well studied at this point. Let’s not just rely on and sensationalize the results of one small pilot study of “biggest losers,’ but rather take away lessons learned from the successful maintainers who are members of the much more reality-based NWCR.

Reference cited:

  1. Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD: Persistent metabolic adaptation 6 years after “the biggest loser” competition. Obesity 2016:n/a-n/a

Losing Weight by Being Active Is Best

Rose Scovel T2D (crop)Did you know that your body stores fat from excess calories in places other than fat cells? Both your muscles and your liver store extra fat as you gain excess fat weight (1). More fat storage in your muscles may decrease the removal of glucose from your blood, making muscles more resistant to insulin if you don’t exercise regularly (2; 3). Given that your muscles are responsible for the majority of blood glucose uptake in response to insulin, developing insulin-resistant muscles has a substantial impact on your blood glucose. Regular exercisers, paradoxically, can store more fat in their muscles without experiencing insulin resistance, suggesting that the total amount of fat stored there isn’t the critical component but rather how muscles respond to insulin (4).

The greater release of insulin that results from eating excessive amounts of carbohydrate may cause you to gain body fat because carbohydrates are usually converted into and stored as fat when you’re sedentary. If you store fat just in fat cells (particularly in the ones under the skin), you probably will not have as many health problems compared to putting it elsewhere. For example, storing extra fat in your liver may contribute to low-level inflammation, which can lead to the development of insulin resistance, diabetes, heart disease, and other metabolic disorders. Therefore, your liver (and whether or not it stores excess fat) may prove to be a crucial link between weight gain and the development of insulin resistance (1).

An insulin-resistant liver may lead to elevated blood fats and cholesterol levels that contribute to the development of heart disease. You can compound the problem by with dietary choices that contribute to your liver’s insulin resistance, including foods high in refined carbohydrates and highly processed ones. You can lower inflammation and improve your metabolic health with lifestyle changes, including exercising more (5). In fact, being active and eating more fiber naturally in your diet are likely the two most important changes you can make to lower your risk of all metabolic diseases (6).

You don’t have to lose a lot of weight: losing just ten pounds improves your insulin action, lowers inflammation, enhances good cholesterol and lowers the bad, improves metabolic efficiency, and reduces type 2 diabetes risk. Going on a diet to lose weight, however, is not the best long-term solution to managing your body weight or reducing your diabetes risk.

Why? Dieting does not work for most people. It becomes progressively harder to lose weight the longer you stay on a diet (thus making it harder for you to stay motivated to follow it); consequently, many people give up after a while.

A bigger problem is that you are not likely to keep off any weight that you do lose. More than nine out of ten dieters who have successfully lost weight ultimately regain the pounds they struggled to lose. If you go back to eating the same foods after your diet ends that you ate before, you will typically rebound by taking in excessive calories, particularly in the form of extra fat that quickly returns you to your former weight. In fact, most people gain back even more than they lost, regardless of the diet they followed. A greater percentage of the weight you regain is usually body fat, ultimately making your body fat higher than if you had never lost any weight.

While your body’s set point—or what you normally weigh—can change gradually over your lifetime, it remains the same over the relatively short time frame of a diet, unless you make permanent lifestyle changes. If you maintain high levels of daily physical activity while you’re losing weight, though, that will help you prevent gaining it back later on (7). So, if you have to choose between dieting and being more active to lose weight, always choose motion, even if weight loss is slower with exercise alone.

References:

  1. Koska J, Stefan N, Permana PA, Weyer C, Sonoda M, Bogardus C, Smith SR, Joanisse DR, Funahashi T, Krakoff J, Bunt JC: Increased fat accumulation in liver may link insulin resistance with subcutaneous abdominal adipocyte enlargement, visceral adiposity, and hypoadiponectinemia in obese individuals. Am J Clin Nutr 2008;87:295-302
  2. Coen PM, Dube JJ, Amati F, Stefanovic-Racic M, Ferrell RE, Toledo FG, Goodpaster BH: Insulin resistance is associated with higher intramyocellular triglycerides in type I but not type II myocytes concomitant with higher ceramide content. Diabetes 2010;59:80-88
  3. Coen PM, Goodpaster BH: Role of intramyocelluar lipids in human health. Trends Endocrinol Metab 2012;
  4. Bergman BC, Butterfield GE, Wolfel EE, Casazza GA, Lopaschuk GD, Brooks GA: Evaluation of exercise and training on muscle lipid metabolism. Am J Physiol 1999;276:E106-117
  5. Zoppini G, Targher G, Zamboni C, Venturi C, Cacciatori V, Moghetti P, Muggeo M: Effects of moderate-intensity exercise training on plasma biomarkers of inflammation and endothelial dysfunction in older patients with type 2 diabetes. Nutr Metab Cardiovasc Dis 2006;16:543-549
  6. Herder C, Peltonen M, Koenig W, Sutfels K, Lindstrom J, Martin S, Ilanne-Parikka P, Eriksson JG, Aunola S, Keinanen-Kiukaanniemi S, Valle TT, Uusitupa M, Kolb H, Tuomilehto J: Anti-inflammatory effect of lifestyle changes in the Finnish Diabetes Prevention Study. Diabetologia 2009;52:433-442
  7. Wang X, Lyles MF, You T, Berry MJ, Rejeski WJ, Nicklas BJ: Weight regain is related to decreases in physical activity during weight loss. Med Sci Sports Exerc 2008;40:1781-1788

Too Overweight and Too Weak to Walk?

Patio umbrellas in SBWe are continually bombarded with messages about how fat Americans have become and how bad this weight gain is for our health. Interestingly, while the United States became the fattest nation in the world during the 20th century, our average life span still increased by 27 years. This conundrum makes us realize that nothing is ever quite what is appears or as simple as we would like it to be. In some cases, weight loss can be good (if it is fat weight alone), but it can also be bad if what you’re losing is your muscle mass instead. In fact, sarcopenia, otherwise known as muscle wasting, can vastly decrease a person’s quality of life and speed up the aging process.

Researchers investigated whether sarcopenia is associated with impairment in insulin sensitivity and glucose homeostasis in both obese and non-obese individuals. Their cross-sectional study included over 14,000 subjects, and sarcopenia was assessed using bioelectrical impedance measurements of total muscle mass.

Not surprisingly, they reported that sarcopenia is associated with insulin resistance in all individuals, regardless of body fatness. It was also more likely to be associated with glycemic abnormalities in the obese subjects. Accordingly, they concluded that sarcopenia, independent of obesity, is associated with adverse glucose metabolism, and the association is strongest in individuals under 60 years of age, which suggests that low muscle mass may be an early predictor of diabetes susceptibility.

Why does this matter to those of us working with diabetes patients? The focus of diabetes management is usually on weight loss, along with important lifestyle improvements. Even the Diabetes Prevention Program is used as the shining example of why all patients should attempt to lose at least 5-7% of their body weight. Often times, though, all the patients hear is that they are supposed to lose weight, and more often than not, the exercise portion of their lifestyle “prescription” goes unfilled. However, weight loss without regular physical activity is a recipe for disaster.

One main problem with large amounts of weight loss after you reach middle-age or older is that these losses consist of about 75 percent fat and 25 percent muscle for typical dieters, but when you gain weight back afterward (which is extremely common within six months to a year), a larger percentage (up to 85 percent) of your lost weight is regained as body fat. Having less muscle also lowers your caloric needs, making it easier to gain weight even when you’re eating the same number of calories after your diet as you were consuming beforehand. Furthermore, people who frequently cycle between weight loss and regain eventually will have insufficient muscle left to carry their extra weight, making them become one of the “fat frail” with sarcopenic obesity likely to have a reduced quality of life.

With weight loss, it is essential that you regularly exercise to maintain your muscle mass. In fact, physical activity is likely more important than how many calories you eat when it comes to maintaining a good body weight and your health. Dieters who fail to exercise lose more muscle mass, but exercising during periods of restricted calorie intake stimulates the retention of your muscle, which also keeps metabolism operating at a higher level.

Another consideration is that when losing excess fat, you are also releasing whatever has been stored in your fat tissue along with it, including a lifetime of accumulated toxins like PCBs and DDEs from insecticides. This rapid increase in levels of circulating toxins can actually lead to nerve damage. In nature, bald eagles rapidly die when they lose weight due to the toxins in their brains that get released. This “poisonous infusion” may be the major reason why major weight loss at an older age (when you have had a longer time for toxins to accumulate) is bad for you. Along the same lines, many medications are also stored in fat tissue, and weight loss releases more of them into your bloodstream. Most physicians fail to reduce the dosage of fat-soluble drugs during periods of weight loss, likely making the doses excessively high.

Even if you’re trying to lose some weight, it likely may not be in your best interest once you’re over 60 years of age: even intentional weight loss in older women results in more than twice the risk of hip fractures, frailty, and nursing home admissions. As you can see, there are many good reasons not to attempt to lose significant amounts of weight once you get past a certain age, potential loss of muscle mass being just one of them.

Although maintaining or even gaining muscle mass through training and supplementation cannot completely prevent and reverse declines in your muscle strength over time, keeping what muscle mass you have and trying to gain more should still optimally be your goal in order to stay looking and feeling younger for longer. At present, resistance exercise is the best treatment for restoring lost muscle mass, and doing such training at any age is also an excellent way to prevent muscle losses from occurring in the first place. Really, the focus should always be on gaining or retaining muscle from regular physical activity rather than losing weight, as doing so will eventually lead to healthy fat weight loss without causing a state of sarcopenia.

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)

Taking Insulin? Avoid Getting Fat!

fat upload

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.

Are Exercise-Induced Lows Making You Fat?

Over the years, I have had many exercisers with diabetes ask me why they’re gaining weight instead of losing it. There are two possible answers to that question. One answer, which is more applicable to new exercisers, is that muscle weighs more than fat (for an equivalent amount). Consequently, if you are gaining muscle while losing some fat weight due to your new exercise regimen, then your scale weight is likely not reflective of the positive changes in your body composition (i.e., less fat, more muscle).

 The second possible answer is more applicable to people who are not new to exercise, especially anyone who may have recently changed the amount or intensity of training that they’re doing. I first ask them, “Have you been treating a lot of low blood sugars recently?” When they invariably reply, “Yes,” then I know to tell them that they have simply been taking in too many extra calories while treating hypoglycemia.

Of course, you have to treat a low if you have one! However, every calorie counts, even the ones that boost your blood sugar back to normal (and beyond). People with diabetes often reach for candy, cola, juice—or other high calorie, high fat, and high sodium foods—to correct lows, which can lead to rebound high blood sugars, unhealthy eating, and weight gain. What you use to correct a low is often just extra calories not accounted for in your daily meal plan.

What can you do to avoid gaining weight when you have to treat frequent lows? The best advice is to treat them with something low in calories, but with enough glucose to bring your sugars back to normal. When you have a hypoglycemic reaction, do not binge on candy bars, cookies, and other high calorie, high fat foods. These “treats” take longer to raise your blood sugar than pure glucose and usually contain calories (like ones from fat) that do not raise blood sugar levels effectively. You are almost certain to eat too much of them waiting for your blood sugar to rise and consume unnecessary extra calories that will cause weight gain—and excess weight gain can lower the ability of your insulin to keep blood sugars in check. You can also end up with rebound hyperglycemia, which may increase your insulin needs and promote fat storage.

I’m going to sound like a walking advertisement for glucose products from here on out, but I fully understand from both professional and personal experience how critical making smart choices is when you want to keep exercising regularly and avoid weight gain. Using fast-acting glucose to raise your blood sugars is likely to contribute the fewest extra calories. Why? Pure glucose contains only 4 calories per gram, so a 15-20 gram treatment has 60-80 calories, and every single calorie goes directly to rapidly correcting your blood sugar levels.

Hypothetically speaking, if you’re correcting just two lows per week with 15 grams of carbs, you will take in an extra 6,240 calories a year, or the equivalent of almost 2 pounds of body fat (one pound of fat is 3,500 calories). By way of comparison, getting 15 grams of carbs from other foods usually results in your consumption of way more calories, especially if any of the foods contain calories coming from fat (9 calories per gram) or protein (4 calories per gram), neither of which will rapidly correct a low blood sugar.

Here are just a few other food comparisons:

  • A 2-ounce bag of Skittles candy contains almost 60 grams of carbohydrate and four times the calories of a 15-gram glucose dose. Likewise, just one ounce of Smarties contain 25 grams, which if you consumed them all would probably raise your blood sugar too much and cause you to take in extra calories.
  • A candy bar like Snickers contains about 100 extra calories for every 15 grams of carbs. Correcting lows with Snickers or other candy bars adds another 3-pound weight gain a year.
  • A regular soda that contains high-fructose corn syrup may take longer to correct a low (fructose has to be converted into glucose first),  and it’s easy to consume more than 15 grams—which is the amount in only 4 ounces of a soda (one third of a 12-ounce can).
  • Even choosing orange juice or a banana to correct a low is less effective because the fructose (fruit sugar) is much more slowly converted into glucose. You probably won’t be able to stick to only 4 ounces of juice or half of a medium banana (15 grams of carbs) while you wait for your low to be corrected, and end up consuming more calories than necessary.

 Check out some calorie intake comparisons using Dex4’s new Hypo Smart Choice Calculator, at http://dex4.com/smartchoice. You’ll likely be surprised how many extra calories you may be consuming just treating low blood sugars with the usual things like orange juice and soda!

There is nothing worse than exercising and trying to lose weight, but ending up gaining some instead due to all the extra calories you eat to correct low blood sugars. If you can prevent lows with diet and medication changes before, during, and after exercise and avoid taking in those extra calories in the first place, certainly do that!  But when you do have to treat an occasional low, keep in mind that using food rather than pure glucose can add a lot of calories to your total yearly intake and your lows may take longer to correct.

In short, pure glucose is always best for rapid treatment of lows, although pure sucrose (table sugar, as found in hard candies) is second best. For prevention of lows during longer bouts of exercise or overnight, however, consider taking in a low-calorie bedtime snack with a balance of carbs, protein, and fat that will keep your blood sugars stable for longer. Some examples are Balance bars, low-fat and reduced sugar yogurt, or low-calorie ice cream. An ounce of prevention is always worth a pound of cure, especially if a hypoglycemic episode leads you to eat everything in sight!