Mayo Advice #4 – Ask the doc for more pills (Aug 2016)

Here’s the full text of this next piece of advice (Avoid weight gain while taking insulin) from the Mayo Clinic website.

Ask your doctor about other diabetes medications. Some diabetes medications that help regulate blood glucose levels — including metformin (Fortamet, Glucophage, others), exenatide (Byetta), liraglutide (Victoza) and pramlintide (Symlin) — may promote weight loss and enable you to reduce your insulin dosage. Ask your doctor if these or other medications would be appropriate as part of your diabetes treatment plan.

I like the goal – reducing Insulin dosage. When I started Insulin my doctor wanted to take me off Metaglip. Only part of that made sense. The Glipizide part of Metaglip is a Sulfonylurea which stimulates the release of more insulin from the pancreas. But we’ve already determined that too much insulin is the problem. Sulfonylurea drugs also decrease insulin resistance which they would pretty much have to do in order to help the extra insulin work.

The diabetic care nurse knew more about the drug than the doctor did. I was able to convince the doctor to prescribe Metformin which the doctor was convinced could not help since my pancreas (he said) no longer produces insulin. He clearly had the meds mixed up. But he has told me since then that as long as it is working for me (and it is) that he will keep prescribing it.

I was on Byetta (Exenatide) which was getting decent results when the diabetic nurse recommended I go to the “gold standard” of care which is insulin with the pump. The mechanism of Byetta is (wikipedia source).

  1. Exenatide augments pancreas response
  2. Exenatide also suppresses pancreatic release of glucagon in response to eating…
  3. Exenatide helps slow down gastric emptying
  4. Exenatide has a subtle yet prolonged effect to reduce appetite…
  5. Exenatide reduces liver fat content

Byetta has some side effects that bother people enough to get them to stop taking it. It’s a shot, like Insulin, so there’s that inconvenience.

I have no experience with the other classes of drugs but if the drug’s net effect is to increase the level of insulin in your blood then it’s bad. Good that it is reducing your blood sugar. Bad that the insulin is what does the damage.

From what I can tell, Metformin is one of the best and it only gets you half way to normal. So yes, ask your doctor about these drugs but focus on the question of whether or not the drug increases the insulin level in your blood. If so, be skeptical.

 

Move More (reprinted from Aug 2016)

Get some aerobic activity can translate into “get off your lazy behind” to some people. I am one of them. Now if I’m more than 100 lbs overweight how easy is it for me to get more exercise? Now suppose I’m eating all three recommended meals and suffering the insulin rise that comes with those meals.

I propose this idea for those who tell me to get more exercise. They need to strap a 120 lb weight on their back and hop on the stair machine or the elliptical. Because that’s what it is like when I get on one of those machines. My pulse rate goes up when I get up to walk to the bathroom. My guess is that my muscle mass is as much as most skinny people. How many of them can walk a mile with a 120 lb weight strapped to them?

I’ve only been on this Intermittent Fasting “diet” for about 10 days but I have a lot more energy. I can’t stay in bed long and I am awake late. I actually cleaned up my kitchen for the first time in 2 years. I cleaned out my living room and hauled a bunch of old bottles to the recycling center today (I am on a week stay-cation with the kids). Most of my house looks like I am no longer a hoarder (a joke not intended to insult those with the real condition).

When I lost 70 lbs back in 1997 I was able to do a lot of physical activity. I rode my bike and roller bladed around the neighborhood (my age at the time was upper 30’s). I long for the day when my body isn’t so pulled down by gravity that I moan to get up.

Benefits of Exercise

It is known that exercise lowers insulin resistance (Acta Med Scand Suppl. 1986;711:55-65. Effects of Exercise on Glucose Tolerance and Insulin Resistance . Brief review and some preliminary results Effects of exercise on glucose tolerance and insulin resistance. Holloszy JO, Schultz J, Kusnierkiewicz J, Hagberg JM, Ehsani AA.). From that page.

Preliminary results are presented in this paper showing that prolonged, strenuous and frequent exercise can also completely normalize GT by decreasing resistance to insulin in some patients with mild non insulin dependent diabetes mellitus (NIDDM) and in some individuals with impaired glucose tolerance (IGT).

What constitutes prolonged, strenuous and frequent exercise? The abstract continues:

The amount of exercise required to normalize GT in such patients appears to be in the range of 25 to 35 km per week of running, or a comparable amount of another form of exercise, performed on a regular basis.

That is 15-21 miles a week. I wonder how many years it would take to work up to that level if exercise? At 4 days a week, that’s running 4-5 miles a day. I am sure there are people who can and do that but really? The level of exercise it would take for a non-mild T2D to reverse their condition is pretty extreme. How many people are able to keep that up over their lifetime without some injury which stops the running?

Add to that their statement:

Exercise appears to be effective in normalizing GT only in patients who still have an adequate capacity to secrete insulin, and in whom insulin resistance is the major cause for abnormal GT.

I wonder how much my pancreas still can make? I guess I will find out as I lower my external Insulin.

“Don’t Skip Meals” says the Mayo Clinic (Reprinted from Aug 2016)

The Mayo Clinic website has advice on avoiding weight gain while taking Insulin. Their second point is “Don’t Skip Meals”. They give three reasons to not skip meals.

Don’t try to cut calories by skipping meals. When you skip a meal, your body is less efficient at using energy, and you’re more likely to make poor diet choices at the next mealtime because you’re too hungry. Skipping meals can also cause low blood sugar levels if you don’t adjust your insulin dose.

Let’s think about each of these reasons.

  1. Skipping meals makes your body less efficient at using energy. I guess that’s another way of saying that it lowers your metabolism. Why is a 7 PM to 7 AM fast OK, but a longer fast, say skipping breakfast not OK?
  2. You’re more likely to make poor diet choices at the next mealtime because you’re too hungry. Could be true in some cases but they really don’t explain what a bad diet choice would be.
  3. Skipping meals can also cause low blood sugar levels if you don’t adjust your insulin dose. I suppose they legally have to do that warning for the chronically stupid people out there.

Some of this advice is based on the notion that breakfast is the most important meal of the day. This notion has been recently put to the test as noted in WebMD (Is Breakfast Really Your Most Important Meal?). The data just doesn’t support the necessity to eat breakfast. There may be some benefits to eating breakfast but the clam that you will eat too much at the next meal has now been shown to be false.

It is ironic that they are concerned about the effect of skipping a particular meal on a person’s metabolism but recommend counting (and limiting) calories over a long span of time. It seems inconceivable that missing one meal will mess up someone’s metabolism but living on 1500 calories a day is somehow OK.

The last point about lowering blood sugar and needing to adjust Insulin levels is a double edged sword. The goal of all of this should be to lower blood sugar and reduce Insulin needs. Yes, we need to carefully monitor our blood sugar during fasting periods but we need to do that when we are stuffing ourselves, too. And even more during fasting.

As to the feeling hungry question. I was eating McDonald’s breakfast of 2 breaakfast burritos every day (and even most weekends). When I stopped eating that breakfast (and started skipping breakfast) I was hungry. For a few days. Then I wasn’t hungry any longer. Now I am skipping lunch too and I do get hungry – around 3 PM. That’s about the right time to get hungry since dinner is in a couple of hours.

For me hunger relates to blood sugar levels. I get hungry when my blood sugar is low. That makes perfect sense. Right now I have cut my basal (background) insulin level from 56 units a day down to 26 units a day. That’s at about 10 days into the Intermittent Fasting.

Basically I am taking their warning and following the opposite advice. I am skipping breakfast and lunch but eating a big dinner. I don’t count calories and I eat as much as I want for dinner. I’ve been doing somewhat lower carbs at somewhere around 100 g of carbs a day. I’m still drinking craft beer (several in the evening).

Most of us T2Ds have been on more diets than we can count. I did PhenFen in 1997 and lost 70 lbs in 3 months. Had all the energy in the world. Rollerbladed around my block several times one night. Now I can’t imagine strapping on the blades.

My first diet was at age 16 when I went from the horrible (I thought at the time) weight of 160 lbs to 128 lbs. Everyone told me I look great. Started a viscous cycle of loss then gain exceeding the loss.

I have tried vegan – did that for most of a year. Already mentioned low carb for 18 months (probably the best choice in diets).

This does lead to some good questions. Can a crashed metabolism be started up again? Does our metabolism slow down as we get older?

Right now I weigh the same as I did in 2003 – right before I was diagnosed as T2D. How have I avoided gaining even more weight? I stopped dieting. Other then being generally low carb I just don’t diet any more.

Dietary Control Blood Sugar via Counting Calories (Reprint from Aug 2016)

The Mayo Clinic site we saw earlier recommends counting calories as a way of preventing weight gain when taking Insulin. Sounds good in theory. After all energy out has to match energy in. If you take in more energy than you put out you gain weight. If you take in less energy than you put out then you lose weight.

The only problem is that it is much, much more complicated than that. Here’s what I see as both sides of the question.

Positive Side of Counting Calories

  • Can be reduced to simpler terms, like exchanges.
  • Can eat until we reach our calorie limit and then stop for the day. This produces an extended fasting time which is good.
  • Being aware if how much we eat by logging can show we are eating a lot more calories than we think we are.

Negative Side of Counting Calories

  • Calories don’t take into account the type of calories consumed and their impact on blood sugar control. A packet of white sugar and a piece of lean chicken breast could have the same number of calories but a completely different response in a T2D. We don’t process them at the same rates (previous BLOG post on this).
  • As an example of the type of calories mattering a controlled study was performed which showed the higher protein and lower carbs group had improved insulin sensitivity and cardiometabolic profile in overweight women. So if the advice is to count calories with the goal of restricting calories then the type of calories need to be considered as very important.
  • The type of calories consumed also affected the bounce back after the diet (Study here: Diets with high or low protein content and glycemic index for weight-loss maintenance). Bottom line is higher protein is better.
  • Counting calories is the standard weight watchers approach and thousands of other companies which want to sell you books and meal plans. It doesn’t work in the long run except for getting repeat customers.
  • My own experience is that I still pick up stuff I buy and look at the labels to see what is in them. I don’t eat bread very often and stay away from most carbs and still have way too much weight.
  • Most of the people I know comment on how I never eat. It’s not like I am secretly binging either. I have been on many restricted calorie diets.
  • The Biggest Loser show does the most extreme intervention of restricted calories and exercise possible and many/most of the people gained the weight back. The ones that only had a modest gain were those who worked as trainers.
  • The biggest problem is the reduction in our metabolism that inevitably happens with a restricted calorie diet. This is a long term effect. That is my problem personally and with this sort of diet. In the case of the Biggest Loser show the study concluded:

By the finale, all their metabolisms had significantly slowed down due to the weight loss from diet and exercise routines, and their bodies were not burning enough calories each day to maintain their thinner frames. This was not a surprise to scientists, because studies have previously found that everyone’s metabolism slows down after a diet. But it was shocking that over the next several years, their metabolisms did not recover and return to the normal rate for a person of their size. Instead, their metabolisms became even slower, which caused the pounds to pack back on.

That is the key and the problem with the counting calories form of dieting. Sure you can lose weight but your metabolism drops.

The advice I give my own children is to not go on a diet to lose. Weight. They will gain the weight back and then more when they permanently alter their metabolism.

Reducing Insulin Results in Weight Loss (Reprinted from Aug 2016)

So if insulin causes weight gain then it would seem to logically follow that reducing insulin will result in weight loss. We know this is the case because if we just stopped taking our insulin we would lose a lot of weight fast*. However, getting rid of your need for external sources of Insulin is a great goal.

In my case, I lost 50+ lbs in six months before I was diagnosed with T2D. That was the body’s natural way of trying to handle the high blood sugar problem. Adding medications just pushed my weight up. That was true with just Metformin. Could this be because the study that the Metformin causes weight loss concept was built on a study of psychiatric patients not on diabetics? Other studies based on pre-T2Ds are equally questionable since their weight loss could be due to poorer control over their blood sugar levels.

This all makes the advice of the typical MD even more absurd when they tell you that “When you get your sugars in order you will be able to lose weight.” How is that even remotely possible when I have to use astronomical amounts of insulin to keep my sugar under control?

Standard Warning

*Stopping your Insulin cold turkey can be bad and people die from doing this. I feel like I need to say this because there are dumb people out there. Don’t drop your Insulin alone for weight loss even if that weight loss itself is good for you. There are other ways. Make sure you monitor your blood sugar level closely no matter what treatment you use.

Leptin and Insulin Resistance (Reprinted from Aug 2016)

Time for the next paradox. (Science is: Relationships between changes in leptin and insulin resistance levels in obese individuals following weight loss).

Moderate weight reduction in obese participants over a short period significantly improved Insulin Resistance.

Maybe this isn’t really a paradox as much as it is a challenge. How do you possibly lose weight when you are on large doses of Insulin?

Next, which was the cause and which was the effect? Did what they do reduce the weight improve Insulin Resistance or did what they do reduce the insulin resistance result in weight loss?

Either way, we’ve now discovered at least one way to reduce Insulin Resistance – weight loss.

One Man’s Resistance is another man’s Sensitivity

Resistance and sensitivity are the inverse of each other. The goal is to improve our cells ability to deal with insulin. Saying it either way as Increase Insulin Sensitivity or Decrease Insulin Resistance is saying the same thing.

 

Metformin and Weight Loss (From Aug 2016)

Metformin is said to do two paradoxical things at the same time:

  1. Metformin lowers insulin resistance which helps glucose to be moved from the bloodstream to the cells (The science: Reducing insulin resistance with metformin: the evidence today).
  2. Metformin used alone results in some weight loss (The science: 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study).

Here’s the paradox. If insulin is only used for pushing fat into cells then Metformin, by lowering insulin resistance should increase weight, right? What am we missing here?

One obvious answer is that insulin is the key to both pushing fat into cells as well as releasing fat from cells. Lowering insulin resistance helps take the fat from the cells and explains Metformin’s advantages. Metformin is like a key which opens the lock and allows glucose in and out of cells.

I know from my own experience that even after 5 years on the pump Metformin still helps my blood sugar levels – by roughly 20 points when taken at bedtime. Instead of waking up at 140 I wake up at 120 by taking Metformin before bed.

Metformin lowers insulin resistance. Lowering our insulin resistance both helps us take up the glucose from our blood into our cells and helps us lose weight.

Take note, I am not saying any of this to advocate for Metformin. The same study showed that Metformin can delay the onset of diabetes by as much as 10 years if given to pre-diabetics. But it is still only a delay.

Insulin and Weight Gain (Reprinted from Aug 2016)

The connection between insulin and weight gain is well understood and acknowledged. From the Mayo Clinic website.

When you take insulin, glucose is able to enter your cells, and glucose levels in your blood drop. This is the desired therapeutic goal. But if you take in more calories than you need to maintain a healthy weight — given your level of activity — your cells will get more glucose than they need. Glucose that your cells don’t use accumulates as fat.

So what is their advice for avoiding this situation? Summarized as

  1. Count Calories
  2. Don’t skip meals
  3. Get aerobic activity
  4. See your doctor about getting on [more] medications
  5. Don’t skip taking your insulin

They pulled out the old tried-and-believed-to-be-true words. That don’t work at all. Nothing makes you feel deprived more than counting your calories. Skipping meals allows your insulin levels to drop. Exercise sounds good in theory but rarely ever gets put into practice. Get more meds which are going to push harder to get the glucose out of the blood into your cells? Sounds like the kind of advice you’d give someone for weight gain, not loss. Finally, don’t go off your insulin for weight loss purposes.

Most of what they say is well-intentioned but completely wrong. All of this explains why we got fat but doesn’t really help us get control of our insulin resistance. Why not tell people that they can skip meals as a way of getting their insulin resistance to improve? Are they so afraid someone will go too low that they don’t want to see people improve their core issue?

Here’s what the advice should be when targeted towards improving insulin resistance.

  1. Don’t count calories. Nothing makes you feel more deprived than counting calories and nothing sets you up for feeling more like a failure. Restricted calorie diets lower your metabolism and you will be worse off for years after the diet since your set point will then be lowered.
  2. Skip meals. At the very least don’t eat just because it’s time to eat. Eat because you are actually hungry. Understand that the fast you did from 7 PM to 7 AM could be stretched out till noon without harming you.
  3. Exercise is always good. If you fast you get more energy and more active naturally. Exercise has lasting effects on blood sugar levels.
  4. Find a doctor who is willing to work with you and explore options that he may not have learned about in medical school. At the very least one that understands what the meds she prescribes to you do and their effects on insulin resistance. At least find a doctor that acknowledges your problem is insulin resistance. (Added List of Low Carb Doctors).
  5. All other things being equal, you can only reduce your insulin needs by lowering your insulin resistance. The goal, therefore, is to figure out how to reduce your insulin usage. Don’t just stop taking insulin and let your insulin levels get really high. I’ve lost a friend recently to DKA so I take this very seriously. She was an undiagnosed T2D but in retrospect she had all of the external markers of a T2D adult.

It might be beneficial to do a post on each of the above treatment points but focus the points on the treatment I am doing now, 18/6 Intermittent Fasting.

Who Would Have Thought? (Repost from Aug 2016)

Who would have thought that lowering insulin use while keeping blood glucose levels stable was even possible? I don’t remember hearing that in my pump training class. They talked about how to increase insulin not decrease insulin.

Who would have thought that it would be this easy to better regulate their blood sugar levels? Skipping breakfast and lunch sounds too simple.

Why does this work?

We fast every day. If we ate our last meal or snack at 8 PM and eat breakfast the next day at 8 AM we’ve just done a 12 hour fast. But for insulin resistant people the Dawn Syndrome robs us of the advantage of that fast. We wake up and our numbers are higher than they should be. Increasing our pump basal amounts doesn’t help either. (In fact, if this model is right it makes it even worse).

How is extending the fast by 4-8 hours beneficial? Well, instead of stepping up from our early number (as breakfast does) we keep steadily going down in blood sugar levels. Dr Feng’s view is that there’s a transition from using stored energy in the liver to stored energy in the body’s fat cells themselves. That transition is how we lose weight and affect the insulin resistance.

A few drugs, like Metformin, can help, but not enough over a long time, We’ve got to extend our reset period and the best way to do that is through fasting.

The Shift in Thinking

The main shift in thinking was going from believing that insulin is a neutral substance which only helps to lower blood sugar. If insulin itself is the problem then treating with insulin is throwing fuel on that same fire. No wonder we keep getting sicker and sicker.

Insulin is a hormone

From this site.

Insulin is a hormone made by the pancreas that allows your body to use sugar (glucose) from carbohydrates in the food that you eat for energy or to store glucose for future use.

The same site says this.

People with type 2 diabetes do not respond well or are resistant to insulin. They may need insulin shots to help them better process sugar and to prevent long-term complications from this disease. Persons with type 2 diabetes may first be treated with oral medications, along with diet and exercise. Since type 2 diabetes is a progressive condition, the longer someone has it, the more likely they will require insulin to maintain blood sugar levels.

So let’s try and follow the conventional wisdom.

  • T2Ds don’t handle insulin well (insulin resistance)
  • T2Ds need shots to get more insulin
  • Eventually oral meds will need to be replaced with insulin in T2Ds.

That’s the best they have to offer on these sites. The problem isn’t blood sugar levels it’s our response to insulin. No real insight is given on how to improve insulin resistance. No comment on the underlying problem at all.

 

My Results – 10 Days In (repost from Aug 2016)

Here’s my ten day progress report on fasting from back in Aug 2016.

Here’s a plot of my insulin over the last month or so. I started the 16/8 Intermittent Fast (skip breakfast and lunch) about 10 days ago.

My daily insulin levels have gone from around 100 units a day to 55 units a day. All by skipping breakfast and lunch and just eating later (5PM-11PM).

I have had good blood glucose numbers over the same period. Here’s the chart over the last 30 days.

My average blood glucose has stablized and is much lower than the peaks from earlier. My pump lists:

Days 7 Avg 125
Days 14 Avg 126
Days 30 Avg 147

It is worth noting that most of the days earlier my bolus was around 30% of the total and the basal was around 70%. That was because there were days where they were 50-50. But most days were much lower. If the recommendation is 50%-50% then my basal was set too high. Yet I never went low. Something is really broken with this whole ever-increasing insulin model.

Fasting seems like a great reset to the ever-increasing insulin model. I am not sure how fast to drop my basal rates. I am now at 26 Units for the day. I think I will drop the insulin every other day by .25 Units per hour.

Nobody else should do what I am doing just because I am doing it, please. You can see how careful I am being to make sure I don’t go high.