Type 1 Diabetes and Weight Management

Over the past couple of years I've been teaching fellow diabetics how to manage their diabetes. You know, the basics like;  food, activity, medication, insulin use and adjustment, stress management, physiology, complications, blood glucose and health monitoring.

During this time I have noticed a trend, and that is;  the challenge of losing weight or better yet, just maintaining weight with type 1 diabetes.  The media as I'm sure you've noticed at most grocery stores and on talk shows (not naming any names of course) group diabetes (both type 1 and type 2) as being the same with little effort on the authors part to explain the difference between the two. They also advertise incessantly about weight loss and diabetes.
But what I'd like to explore is the topic of weight loss and maintenance when it comes to type 1 diabetes. I mean healthy weight loss, not the loss that comes from ketoacidosis and insanely high sugar levels. Why do I think this topic is important, well I also notice that Type 1 diabetics are gaining weight putting them into the insulin resistant abdominal obesity high BMI health risk category. And a lot of people I see with Type 1 have a desire to learn more about weight loss.

I feel that Type 1's  have very little guidance on losing weight and safely adjusting insulin levels to do so. When I have sought guidance on this subject in the past I get the usual verbal nonsense.  "Increase activity, eat less"  I begrudge that scripted response that seems to be ingrained in thought and promoted with out question by most world government health agencies. Fair enough, create a caloric deficit and lose weight, simple, right? NOT!

I am sure a lot of folks out their that have lived with diabetes long enough can tell you basically how to lose weight, but what about giving formal advice. I find that there are numerous studies and information for Type 2 DM with regards to weight loss.  But what about insulin dependent diabetes or more specifically type 1 diabetes?

Weight loss and type 1 is logical to me. Look up insulin in any Medical Physiology textbook and it will clearly tell you that this essential hormone is not only responsible for utilizing and storing glucose but it is also responsible for Fat and protein storage and utilization. Hmmmm.........What the heck am I getting at?

Keeping in mind that Lipolysis is fat breakdown (A good thing) and Adipose is fat tissue/cells (A bad thing)

Lower your insulin and lower your energy storage. It is common knowledge that when a person is started on insulin they usually put on weight. I know from personal experience that the more insulin I take the more weight I gain. The question is why and more importantly what to do about it.

This is not new info at all by the way. Most carb reduced diet plans rely on this to get results. Even weight watchers tend to promote products that are lower in carb, just looking at the bread products they market. Carbs increase blood sugar, blood sugar requires insulin to put it where it needs to go, into the cells for energy, and any unused energy goes to fat, liver and muscle for later use. Or something to that effect, I am by no means a biochemist. All I know is; when I reduce my insulin levels, I always lose weight.

The number one precursor to insulin needs is the amount of carb we choose to consume in our diet. Number two is how little activity we do in a day. Number three is stressors placed on our bodies.

Eating large amounts of carbs = taking large amounts of insulin = storing more energy as fat = weight gain

Inactivity = Less energy used = more insulin requirements = more stored fat and less stored energy used = weight gain

Stress = increased resistance = increased liver output of fuel (glucose) = higher glucose = more corrections or more insulin = more weight gain

Notice the trend: more insulin = more storage = more weight gain

Lower carb (not extreme) = less insulin = less fat storage = weight loss
More activity = lower insulin requirements = less fat storage = weight loss

Less stress or more sleep = less free floating glucose = less insulin (or correction doses) = weight loss

Easy,  right?  Well not always.  Here are a couple of other things to consider.

You need to have the right insulin(s) and or delivery methods. MDI or Pump. You need to be willing to test a lot,  I mean a lot. You will fluctuate at first but given time and good record keeping, things will even out. Try to eat the same amounts of carb for each meal. Eat protein for each meal, then carb free choices, then slow carb choices - More on the specifics later if any one manages to read this or expresses interest in knowing more.

Cheers!

Trev

Pro Carb or Low Carb?

I must say, the debate is on!  I am not an extremist, as I believe in moderation but a popular topic in the field of diabetes, especially diabetes and weight loss is, as the title depicts, should we eat high carb, low fat, or low carb, high protein, mod fat.  What should we eat?

I am reading a book at the moment called Living Low Carb, great book!  The author Jonny Bowden compares all the low carb diets on the market. His writing style is witty, fun, and makes complicated biochemistry seem interesting, seriously, definitely worth a read! 

The author uses an analogy to clearly display how silly the current stance is for most health care providers, dietitians and associations that place huge emphasis on how carbs are absolutely essential for a healthy diet.


I love Mr Bowden's illustration:

He talks about a time he was lecturing to a large group.  He tells the group that he going to divide them in half. He explains that they are going to be stranded on a deserted island. The first half will be given only carbohydrate to survive on, and the second half will be given protein and fat but zero carbohydrate.  Then, he asks the audience who will be alive in 12 months.

The answer, backed by research  according to his literature review,  is the group that consumed protein and fat . This claim begs the question; are we being told to consume so much bloody carbohydrate when it's not essential for our survival. So I did my own lit search, not a google search but an actual lit search.

I do believe Mr Bowden and the Low Carb crew may be onto something.

The first study article written by Dyson, P and colleagues  in Diabetic Medicine took 13 Type 2 diabetics and 13 non-diabetic subjects. They were randomly placed on a low carb diet (less then 40 gms per day) or the usual diet recommended by the UK diabetes association.  They were assessed monthly for three months.  Guess what the results were?  Those assigned to the low carb eating plan, lost more weight but had minimal changes to lipids and A1C levels.  "The diet was equally effective in those with and without diabetes.
So onto the next study"  Okay good info, interesting.....

Another study done by Shai, Iris R.D and colleagues in the New England Journal of Medicine compared weight loss with three mainstream diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non-restricted-calorie. What did they find?

When they randomly assigned 322 moderately obese subjects to one of the three group they concluded that:
"Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal preferences and metabolic considerations might inform individualized tailoring of dietary interventions."

Clear as mud right, so what they are telling us is that a lower Carb higher healthy fat diet may be a good alternative compared to the 60-75 % high carb diets normally recommended to us battling the big D. 
Okay, moving on......

The last study authored by  Brinkworth and colleagues in Diabetologia  randomly assigned 66 obese subjects to either a low carb (40 % carb/30% protein)or high carb(55% carb/15% protein) diet.  The results were "A high-protein weight-reduction diet may in the long term have a more favourable cardiovascular risk profile than a low-protein diet with similar weight reduction in people with Type 2 diabetes."

So you can loose weight, increase the good fat HDL, with no apparent adverse effect?  Sounds good!

After reading the books, doing a bit of a lit review(not an exhaustive one).  I try to remain unbiased, but the evidence is mounting in favour of a reduced carbohydrate way of eating.  I know that the more carb I consume, the more insulin I need, the hungrier I am, the bigger my waist gets and most importantly the sugars are way harder to control. 

Are you pro carb or low carb or somewhere in between?

Trev

Sources:
Dyson, P. A.; Beatty, S.; Matthews, D. R.(2007). A low-carbohydrate diet is more effective in reducing body weight than healthy eating in both diabetic and non-diabetic subjects, Diabetic Medicine. 24(12):1430-1435.

Shai, Iris R.D et al.(2008).  Weight Loss with a Low Carbohydrate, Mediterranean, or Low-Fat Diet,

Brinkworth, G. D. 1; Noakes, M. 1; Parker, B. 1; Foster, P. 1; Clifton, P. M. (2004).
Long-term effects o advice to consume a high-protein, low-fat diet, rather than a conventional weight-loss diet, in obese adults with Type 2 diabetes: one-year follow-up of a randomised trial, Diabetologia. 47(10):1677-1686.New England Journal of Medicine. 359(3):229-241.

What's up with the Food Guide!

Hello all you wonderful people!

As a nurse educator I am required to teach others with diabetes how to eat properly(well that's not all I do)  Yes, we have dietitian's for that during group programs.  However,  I do a lot of follow up with my diabetic patients.

I am required to cover the basics like, food choices, portions sizes, food types, fiber, etc.

So before every meeting, I must  reluctantly grab the Food Guide.  I say reluctantly for a few reasons.

The original Food Rules was designed and published in the 1940's, yes, the 40's when people were actually needing to gain weight, and suffered from malnourished diseases like scurvy, vitamin deficiencies.

Fast forward to now.  Go to the mall and look around and it is unfortunately obvious that we are no longer malnourished.

So I enter the room to advise my patient on proper eating, using a tool invented in the 40's, although it has been modified over the years.  At least now in Canada the fruits and vegetables are prioritized to the top, not starches like before. Unfortunately protein is on the bottom.

It is let's just say a professional dilemma for me to advise a person with diabetes to consume huge amounts of carbohydrate. Let's just kill the little Islet cells they have left shall we(Sense the sarcasm) Anyhow, I need a job so I have to follow the rules.

So there I am sitting across from an individual who tells me "I have been following the guide as recommended, and I am gaining weight, my blood fats(lipids) keep getting worse, and my diabetes is getting harder to control"
What do I say?  I can tell you what I want to say, which is,  stop eating so much carb, and grill yourself some lean steak and omega three eggs for breakfast instead of the 2 cups of cold cereal loaded with 80 grams of CHO(carbohydrate)

Back to reality. Don't worry, I rely on other tools.

I discuss the fact that obviously the plan is not working, so perhaps try reducing your carb intake by 10-20 grams per meal, add some lower carb vegetables, and increase the leaner proteins. I also explain the concept of glycemic index, fiber, and the role of fat and protein in satiety.

I encourage them to simply explore the literature, trial and error, and to ask themselves if their current method is actually working.

Basically I give them some food for thought, no pun intended.

I am glad that more and more people are considering lower carbohydrate diets as a healthy and legitimate weight loss strategy.  I am also glad that more and more research is being done on the effects of a lower CHO diet.

One final note: I tell them to shop on the perimeter of the grocery store and avoid the inner isles where all the super-carb loaded food is stored.

Trev