by Marion Nestle
Feb 5 2012

Weight loss key to fighting type 2 diabetes

So many comments came in to my blog post on Paula Deen’s diabetes announcement, “weighing in on Paula Deen,” that I thought it was worth revisiting in my monthly (first Sunday) column in the San Francisco Chronicle.  The question (edited) came from a blog reader:

Q: I have been diagnosed with type 2 diabetes and am very confused about insulin resistance, and what carbohydrates I can and cannot eat. So much of what I read is contradictory.

A: The first line of defense against type 2 diabetes is weight loss, but you would never know it from listening to Paula Deen, the celebrity Southern cook who recently announced that she has this disease, or even to the American Diabetes Association.

Having diabetes is no joke. It is a leading cause of blindness, kidney failure, leg and foot amputations, and premature death.

The disease comes in two forms – type 1 and type 2 – but type 2 accounts for 95 percent of cases. In both, levels of blood sugar are too high as a result of problems with insulin, a hormone that enables the body to use blood sugar for energy. But the reasons differ.

Type 1 is an autoimmune disease. It causes the pancreas to stop making insulin or not make enough. Type 1 is not yet preventable and requires insulin treatment.

In type 2, insulin may be available, but body tissues resist its use.

Being overweight is the key factor in type 2. Most people can prevent it by not gaining weight. And most people with the type 2 disease can eliminate symptoms by losing some weight.

Genetics is certainly a factor – many overweight people never develop the disease – but 85 percent or more of people diagnosed with type 2 diabetes are overweight or obese.

In genetically predisposed people, being overweight causes insulin resistance. Metabolism does not handle excess calories very well, and this means calories from any source, not just carbohydrates.

Fast food, soft drinks

Children and adults who habitually consume fast food as well as soft drinks tend to take in more calories and weigh more and are more likely to develop symptoms than people who eat healthier diets and are more active.

This makes healthy eating and physical activity the most important approaches. The vast majority of overweight people at risk of type 2 diabetes can prevent symptoms by losing a few percent of their body weight and doing a couple of hours a week of moderate – not necessarily vigorous – physical activity. The same works for treatment. Some people will still need medications, but the drugs work better with diet and physical activity.

As the Centers for Disease Control puts it, “all diabetes-care programs should make healthy weight a priority.”

Dietary advice for type 2 diabetes is the same as advice for everyone else: Eat a wide variety of relatively unprocessed foods, especially vegetables, fruits and whole grains, and don’t consume too much junk food or too many sugary beverages.

Scientists may argue endlessly about the relative importance of calories, sugars and refined carbohydrates in the diets of people with type 2 diabetes, but everyone agrees that eating less of all three would help resolve symptoms.

Why isn’t weight loss better recognized as a treatment strategy? Paula Deen’s announcement said nothing about losing weight.

The ADA does talk about weight loss on its website ( www.diabetes.org), but you must search hard through several complicated screens before you find, “Losing just a few pounds through exercise and eating well can help with your diabetes control and can reduce your risk for other health problems.”

Pharmaceuticals

I can’t help wondering if the lack of prominence given to weight loss might have something to do with the influence of pharmaceutical companies.

A few years ago, I gave a talk on the importance of weight loss in control of type 2 diabetes at an ADA annual meeting. Although many conference talks dealt with drug treatment, mine was the only one on diet – except for a session on sugars sponsored by Coca-Cola.

The exhibit hall was packed with drug company representatives dispensing free pens, writing pads, books, lab coats and stethoscopes – all with corporate logos.

The influence of drug companies on diabetes advice is worth attention. Deen represents a drug that costs hundreds of dollars a month. Drug companies give the ADA millions every year.

Eating less and being active make no money for anyone (unless people can be induced to join commercial weight-loss programs).

Losing weight is a losing battle for many people. It’s hard to lose weight in today’s “eat more” food marketing environment.

Teachable moment

But a diagnosis of type 2 diabetes should be a teachable moment. Shouldn’t the ADA more strongly urge people with the disease to eat less, eat better and move more, and help everyone find ways to cope with “eat more” messages?

The health and economic costs of type 2 diabetes, and its preventability, are reason enough to demand changes in the food environment. The ADA should be working hard to make it easier for everyone to eat more healthfully, be more active and avoid the need for a lifetime of diabetes medications.

Marion Nestle is the author of “Food Politics” and “What to Eat,” among other books, and is a professor in the nutrition, food studies and public health department at New York University. She blogs at www.foodpolitics.com. E-mail comments to food@sfchronicle.com.

This article appeared on page G – 4 of the San Francisco Chronicle

  • Suzanne

    I mentioned a two week sample of each eating approach to show you how to lower your blood glucose levels without any additional intervention. What you can achieve is stunning. Managing insulin/glucose levels is an excellent way to diminish cardiovascular risk, which I believe you are concerned about.

    At some point in time if your blood glucose levels are not stabilizing at an acceptable level, you might recall the conversation here and research to your satisfaction. Best of luck.

  • Janknitz

    I agree with your conclusion that drug companies have a vested interest in keeping the focus on diabetes drugs instead of dietary and lifestyle changes, but I take issue with your approach.

    Specifically two things:
    1. What makes you think that every obese person hasn’t tried eating less and moving more??? To claim that the solution is that simple is to imply that every obese person is too lazy and stupid to do the obvious.

    Nobody wants to be obese, and scratching the surface of any obese person will reveal a person who has tried numerous “eat less move more” schemes that worked temprorarily if at all and caused the body weight set point to be reset ever higher in the body’s attempt to avoid starvation at the molecular level. News Flash–Eat less, move more DOES NOT WORK in the long term.

    2. What came first, the chicken or the egg? Did obesity cause insulin resistance, or did insulin resistance cause obesity? Gary Taubes and many others believe that the insulin resistance comes first, and simply losing weight, without correcting the underlying metabolic issue, will not cure insulin resistance. Dr. Mary Vernon states that she sees many thin people who are “metabolically obese” because of severe insulin resistance despite a lean body type.

    My own personal experience is nothing but an anecdotal, N=1 story, but nevertheless is illustrative. I have PCOS. I was a thin adolescent and young adult with very severe PCOS. I was not obese when I married and we started trying to conceive–5’3″ and 110 pounds. Yet I had very few non-ovulatory periods and other symptoms of severe PCOS. It took 3 years of fertility treatments and 2 IVF cycles to conceive my first child.

    I rapidly gained weight from the fertility hormone treatments and in the years after my first child was born. When research finally began to show that PCOS is more of a metabolic issue than a reproductive one, I adopted a low carb diet and went on Metformin. Within a month of starting this regimen, BEFORE any appreciable weight loss, I had my first ovulatory period EVER. Weight came off more rapidly than it ever had in all my previous failed attempts on WW and other “eat less, move more” schemes. I wasn’t even exercising much at that time because I was working 2 jobs and attending night school (aren’t I the picture of a lazy, fat slob!). 6 months later, to my utter surprise, I was pregnant.

    In my case, there is NO question that insulin resistance came first and contributed to the obesity (I’m not rejecting my own responsibility for what I put in my mouth, but insulin resistance was a huge driving force in that as well). Within 1 month of reducing insulin resistance, symptoms were dramatically improved. Weight loss was secondary.

    You do a grave disservice to suggest that weight loss alone will improve insulin resistance. Weight loss with a high carb, low fat diet will not have the desired effect–in fact higher carbs can make insulin resistance worse and require an individual to need MORE medication, regardless of any weight lost.

    Weight loss is always a positive thing, but people need more tools than “eat less, move more” to assure long term success.

  • Suzanne

    Thank you for sharing your story, Janknitz. We are fighting an uphill battle, as we are many, many N=1’s. I agree with you 100% that “eat less move more” is not the answer to metabolic disturbance!

  • Margeretrc

    @Hylin,
    Ok, what I meant was anything which raises blood glucose significantly and reasonably fast should be avoided or eaten sparingly. Everything except pure fat (I saw no values for fat alone in the PDF you linked) does cause some insulin response–true enough, and I did not say otherwise. But people have to eat. Even diabetics. Choosing foods that raise BG less (meats, non starchy vegetables), rather than more (grains, starchy vegetables, legumes, sweets) seems like a reasonable strategy to me. Or one could choose to eat whatever one wishes and take meds. I know people like that.
    Actually, pigs, in particular, are anatomically and physiologically not as dissimilar to people as you would think and you cannot completely discount that similarity. Pigs, like people, are omnivores and would happily eat meat and thrive on it if given the chance. But we don’t give them that chance because a) we don’t want trichinosis and b) we want fat pigs–they do indeed grow fat on a diet of grains–ask any farmer. If you think people don’t, take a look at the obesity statistics and the typical American diet, which is also high in grains (as recommended by the USDA). Think that’s a coincidence?

  • Margeretrc

    Sorry. Hylton.

  • Peggy Holloway

    Gary Taubes’s landmark book “Good Calories, Bad Calories” includes exhaustive references to studies that either debunk the “lipid hypothesis” of fat,saturated fat in particular, causing heart disease or show the poor quality of science used in all of those studies. The book is about 1/3 references, so Murph could be busy for quite a while.
    I’m so surprised that anyone still buys the fat fallacy when the science is absolutely clear and easily available.
    I do not pay any attention to epidemiological “studies” which are self-reported diaries submitted by individuals and are notoriously unreliable. The other problem with this sort of “research,” is that the “scientists” comb through mountains of this self-reported data looking for correlations, usually looking for anything that supports their pre-existing hypotheses. Then, their reports, especially as published by the media, mistakes correlation for causation. That’s exactly how we got 50 years of the “lipid hypothesis” foisted on us by Ancel Keys and his 7 Nations Study that has destroyed the health of much of Western society. I’m surprised Murph has never heard of Ancel Keys, George McGovern, and the bad science that spawned the promotion of lowfat diets and the epidemics of obesity and “diabetes” that ensued. So, read Gary Taubes, who tells the story. Or for better entertainment, watch the documentary “Fathead” by Tom Naughton. He also does a good job of describing the folly of the fat fallacy.
    Again read the Phinney/Volek book which is full of good science, written for medical professionals, but easy to understand. The book cites exactly the sort of research (real, lab studies) that Murph is seeking. The difficulty is that true double-blind, controlled studies of human behavior are very hard to conduct. Perhaps all of the n=1 experiments described by the commentators here add up to one big study. You can add me to the list. Is 12 years long enough to prove the efficacy of a low-carb, high-fat diet? That’s how long my brother and I have been low-carbing. With our family history, it’s proof enough to me that low-carb normalizes weight and blood sugar in people with genetic insulin resistance.

  • Benboom

    Hylton: “That book [Wheatbelly] is atrocious. Please reconsider where you procure your nutritional information.”

    Hylton, if you had read any Jane Austen you would know that a jibe is not a rebuttal.

  • Peggy Holloway

    Yancy WS Jr, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med 2004;140:769–77.
    This is just one of the studies conducted by Eric Westman, et. al.
    There was also the Krauss Study, a meta-analysis of countless nutrition studies over the years that concluded that there is no correlation between saturated fat consumption and heart disease and the the nutrition class that is most closely associated with risk for heart disease is dietary carbohydrate. I don’t have the link but Jimmy Moore’s blog has a major discussion of this study in its archives.

  • Margeretrc

    @Peggy Holloway, here are links to the studies you mention.
    http://www.ajcn.org/content/86/2/276.full is the link to the first study, which I’m sure won’t be satisfactory to @murph et al due to the short length of the study and the fact that there were additional variables–supplement, for example, given only to the low carbohydrate group.
    http://www.ajcn.org/content/86/2/276.full is the link to the second study–the meta-analysis. This article, as far as I’m concerned, says it all: The conclusion of the study: “A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD. More data are needed to elucidate whether CVD risks are likely to be influenced by the specific nutrients used to replace saturated fat.” Since it is epidemiological studies that implicated sat fat in the first place, it is valid to use epidemiological studies to vindicate it.

  • Margeretrc

    @Hylton, “What I cannot tolerate is some of the really poor arguments bandied about as facts by many low-carb advocates.” such as?

  • Margeretrc

    @murph, “Science isn’t about picking a champion before the results are in.” It’s funny you should say that, because it was decided that sat fat is the villain before the results were in, yet you (and millions of others, including your doctors), have no problem accepting that.
    “I’d certainly like to see the study that undoes the correlation between saturated fats and elevated risk of heart disease.” Here’s one, which is actually more than one as it is a meta-analysis. (I linked it already in a previous post, but it doesn’t hurt to repeat.) http://www.ajcn.org/content/86/2/276.full Conclusion: “A meta-analysis of prospective epidemiologic studies showed that there is no significant evidence for concluding that dietary saturated fat is associated with an increased risk of CHD or CVD. More data are needed to elucidate whether CVD risks are likely to be influenced by the specific nutrients used to replace saturated fat.”

  • http://diabetesdaily.com/farrell Bernard Farrell

    Can I offer a correction to your excellent post?

    Diabetes is not the leading cause of the problems you list, poorly-controlled diabetes can lead to these. As a person with type 1 diabetes for 40 years, I’m doing just fine.

  • Emma

    DAMN skippy! And I’ll add that the traditional Japanese diet, based on rice (or, in times of bad rice harvests, millet), fish, relatively unprocessed soy, and lots of vegetables, has long been considered one of the planet’s healthiest.

  • http://fatgoneproductreviews.com/ Jasmine Hebert

    Hello,

    I have a 6-year old son who is grossly overweight and I am kind of worried for him. Can you recommend some weight loss tips for him? Almost all the weight loss solutions I found online are meant either for teens or adults! Many thanks for your help!

  • Margeretrc

    @Jasmine, Feed your son real food: meat, eggs, fish if he’ll eat it, full fat dairy, vegetables (mostly non starchy ones), nuts and nut butters, and low sugar fruits like berries. Stay away from processed foods–the cereals, breads, cookies. Ditch the fruit juice, soda, and any other sugared beverages (flavored milk, for example.) Lots of people eating Paleo or Primal are feeding their kids of all ages this way, too. Here’s a link to the blog of a brand new doctor who (I think) is going to specialize in Pediatrics, has a kid, and has made it her business to learn way more about nutrition than most doctors: primalmeded.com Good luck. You are right to be worried, but there really is a solution.

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