Tag Archive for: diabetes

Childhood Obesity: A Family Thing

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I hope you took some time to scan the Executive Summary of American Association of Pediatrics Guidelines for Physicians. If you couldn’t, here are the three things that stood out to me.

Screening by Pediatricians and Primary Care Physicians

The focus of the guidelines was to assess risk factors for degenerative disease such as heart disease and diabetes in children who exceed the 85th percentile of the normal growth charts, indicating overweight, and 95th percentile, indicating obesity. The guidelines recommend beginning at 2 years of age and continuing through 18.

Were there recommendations for the use of medications and bariatric surgery in children over 12 and 14 respectively? Yes, but they were referrals to specialists for evaluations, not a blank invitation to write prescriptions.

It Must Be a Family Thing

Without exception, the guidelines recommend intensive health behavior and lifestyle treatment. “Health behavior and lifestyle treatment is more effective with greater contact hours; the most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a three- to twelve-month period.”

That’s not the same as giving Mom and Dad a diet for the child and sending them on their way. Family-based programs have demonstrated great success, but it has to be a family thing.

It’s All About the Money

The summary also talked about obstacles to the family-based treatment approach. The major obstacle is money:

  • Money for training pediatricians and family practice physicians on how to assess childhood obesity.
  • Money for training more people to teach and work with families—it’s labor intensive.
  • Money for public health and community programs that can support the family-based approach.

It’s a situation we’ve seen many times: Everyone knows how important preventive healthcare and early treatment is, but no one wants to pay for it. But maybe we shouldn’t always look to government to foot the bill; maybe schools, community organizations, and churches could offer programs for their members. If what we’ve always done isn’t working, let’s try something different.

The Bottom Line

The guidelines introduce a couple of new approaches for those with the most severe weight problems, but the focus is on intensive nutrition and behavior-change training for the entire family. That’s not just “Here’s a diet and exercise program, and I’ll see you next year.” The guidelines give a reasonable approach to help the future health of the nation. The approach is simple: Eat less. Eat better. Move more. What they’re saying is that healthcare professionals need training to be able to do that effectively as a team in a reasonable family-based approach. That’s the right approach as I see it.

What are you prepared to do today?

        Dr. Chet

Reference: Pediatrics e2022060641.https://doi.org/10.1542/peds.2022-060641

Is It Worth It?

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At an obesity conference, the report on the clinical trials for a pre-diabetes and diabetes medication left the crowd on their feet and cheering. There are reports of well-known personalities who’ve used the drug with great results. But the ultimate question about a pharmaceutical approach to obesity has to be this: is it worth the money? Let’s start by looking at the pharmaceutical and then the return on investment.

How It Works

The body makes proteins called incretins which can stimulate the release of insulin. One incretin hormone, GLP-1 (glucagon-like peptide-1), is manufactured in the upper digestive system in response to carbohydrate intake. In subjects with type 2 diabetes, this hormone effect is diminished or no longer present.

The ability to stimulate the production of insulin and prevent the release of glucose by glucagon can be stimulated pharmacologically by semaglutide, a receptor agonist—that means it turns on the glucagon. In subjects with type 2 diabetes, semaglutide stimulates GLP-1 receptors significantly, thereby reducing blood glucose and improving glycemic control. In addition, it has multiple effects on various organ systems; most relevant are a reduction in appetite and food intake, leading to weight loss in the long term. Since GLP-1 secretion from the gut seems to be impaired in obese subjects, it was logical to test it in obese populations. Those were the study results I reported on Tuesday.

All in all, this sounds like it might be a potential solution to our obesity crisis, but there are some unanswered questions. What is the long-term safety of regular use of the drug? How does the microbiome impact the effectiveness of the drug? But more than that, everything comes with a price, which begs the question: is it worth it?

The Price

The price of using semaglutide for obesity is really two-fold. First is the actual cost of the weekly injections which is about $1,400 per month at retail. If your insurance will cover it, I’ve seen prices as low as $25 per month. We know that people lost an average of 18% of their starting weight at 68 weeks—the length of the longest study to date—but the rate of weight loss declined near the end of the study. How long will insurance cover it beyond that, and will a person continue to lose weight? We don’t know.

After using the drug for 20 weeks, the placebo group was switched to a placebo and immediately began to gain weight. By the end of 68 weeks, they had regained all but 5% and were still gaining. Would an investment of close to $17,000 to lose about 20% of your weight be worth it if you began to gain it back? There are many questions around whether people can take this drug for the rest of their lives; every pharmaceutical intervention must have an end strategy. The researchers did not address the issue.

The Bottom Line

The research into this pharmaceutical intervention was well done. However, unless the intervention includes an exit strategy, it could be a waste of money. Perhaps a lower carbohydrate diet may be a partial solution because this drug impacts carbohydrate metabolism. But we don’t know whether the weight loss would be enough to have the body take over and do the same thing on GP-1 by itself.

I think this shows a hopeful approach and it may turn out to be a boost to someone who is absolutely willing to change their lifestyle or someone who needs to lose weight for a specific purpose, such as joint replacement surgery or preparing for IVF. But for most of us, maybe it’s better to save the time and money and do what we know works: Eat less. Eat better. Move more.

What are you prepared to do today?

        Dr. Chet

References:
1. JAMA. 2021;325(14):1414-1425. doi:10.1001/jama.2021.3224
2. JAMA. 2022;327(2):138-150. doi:10.1001/jama.2021.23619

Happy New Year!

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It’s good to be back talking to all of you again. The New Year is a time of optimism, everything seems possible, and there’s an enthusiasm for achieving health goals. One thing many people want to do is to lose some weight. It seems appropriate to cover a couple of drugs that were recently approved by the FDA to treat obesity. They’re a pharmaceutical approach to weight loss, and they’ve gotten so much press I have to cover them.

You’ve probably seen the commercials for a pre-diabetes and diabetes medication called Ozempic. It also has a sister drug called Wegovy that was approved for use in teens. In at least two clinical trials, subjects who had weekly injections of the drug lost at least 15% or more of their body weight in 68 weeks. Those who were switched to placebo injections started to gain back the weight they lost. All subjects were supported with monthly consultations with dieticians to induce a 500-calorie reduction in food intake and to increase exercise levels. Markers for type 2 diabetes improved such as HbA1c and blood glucose.

Is this the be-all and end-all to the obesity epidemic? And exactly how does this drug work? I’ll cover that on Saturday.

What are you prepared to do today?

        Dr. Chet

References:
1. JAMA. 2021;325(14):1414-1425. doi:10.1001/jama.2021.3224
2. JAMA. 2022;327(2):138-150. doi:10.1001/jama.2021.23619

What Not to Do When You Want to Lose Weight

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How did my mother-in-law lose 30 pounds when she was completely sedentary? I’ll tell you, but let me tell you first what not to do. Why begin there? Permanently changing your weight (or any other significant health goal) takes a lifetime commitment. You don’t know what life will bring, so the best way to attack the problem is by doing the best you can every day until you really have changed your habits permanently.

What You Don’t Have to Do

When you’re ready to make a change in your lifestyle, especially to lose weight, you don’t have to announce it on social media. If you want to keep track of your progress and do something with that information later, fine. But not everyone responds the same way to social scrutiny and it can be brutal. The only person you ever have to be accountable to is yourself.

You don’t have to throw out everything that’s in your refrigerator or freezer or clean out your pantry. It’s a good idea to get rid of the food that’s two years or more past its “best by” date, but that’s it.

You don’t have to follow any specific diet or exercise program when you start. Eat a little bit less and move a little bit more.

Understanding How to Start

Whether you want to lose weight, lower your cholesterol, reduce your risk of type 2 diabetes, you start slow and you add a little bit to it each day.

Think about this related to weight loss. You can’t fast (by the most common definition of fasting—abstaining from food) long enough to lose all the weight that you want to lose. It wouldn’t be healthy not to eat. Your body’s going to continue to produce waste products and you need nutrients, fresh nutrients, to help it do that.

What you can do is improve the quality of your diet a servings of grapes per day or a small salad before your meal to help suppress your appetite. Every small step is an important one. The catch is that you have to maintain it. So whether it’s a serving of grapes one day and strawberries the next and blueberries after that, add that serving of fruit every day. Or vegetables. Or nuts and seeds. You have to change your eating style permanently.

Turns out, losing weight that way takes some time. But let me ask you this question: did you sit down at a table one day and decide that you were going to overeat and overeat and overeat every second of every day so that you could put on 25, 50, or 100 pounds? Of course you didn’t. What makes you think you can take it off all at once? You have to do it one bite at a time, one meal at a time, one day at a time, just like you put it on.

The Bottom Line

I’m sure you’ve figured out why my mother-in-law was able to lose weight even though conventional exercise wasn’t an option: she consistently ate less than her body needed to maintain her weight. She stopped eating desserts and snacks and didn’t go back for seconds. Even though her body wasn’t as strong as it had been, she still had the mental toughness to stick to her plan, and it worked.

Consistency—what a concept! No fad diet, no keto or paleo, just consistently eating more of the healthier food and avoiding empty calories. I’ll say it again: it was, it is, and it will always be about the calories. It all comes down to a single question:

What are you prepared to do today?

        Dr. Chet

P.S. There’s a new Straight Talk on Health for Members and Insiders, and I’ve done something a little different. I took the Memos from the week and expanded on what I wrote. More about how my mother-in-law was able to lose weight while being sedentary and tips for other goals such as decreasing pre-diabetes and high blood pressure. If you don’t have a membership, this would be a good time to start.

Weight Loss Is Always Possible

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After last week’s Memos, you may think that you have to do something radical to address your body weight or some other health situation, but that’s not the case. You can lose weight under the most extreme conditions, even if you’re completely sedentary. Let me tell you about my mother-in-law, Ruth Jones.

My mother-in-law struggled with her weight for decades. I don’t know what her peak weight was, but I would estimate around 240 pounds. She maintained around 200 pounds for most of the time I knew her. She had severe arthritis in her knees and because she wouldn’t have been able to do the rehab, the decision was made to replace them both at once. She did great at lifestyle and occupational therapy, but she never quite got the complete mobility she thought she would get because the physical therapy was more of a challenge than she could handle. She was able to get around the house but used a wheelchair or scooter in public.

A few years later, she had a very bad reaction to a new statin that damaged a great deal of muscle mass, and she remained in long-term care until she died several years later. But here’s the thing. Even though wheelchair bound, she was able to lose 30 or so pounds; that’s discounting the last few months before she died when she lost interest in eating.

How? How was she able to do it?

How about you—are you ready to make a change in your weight? Blood pressure? Prediabetes? Then you really don’t want to miss Saturday’s Memo.

What are you prepared to do today?

        Dr. Chet

Want Fewer Medications? Change Your Lifestyle

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The study that we examined on Tuesday showed that a regular exercise program can help reduce the number of medications related to cardiovascular disease and type 2 diabetes. We’re not talking about youngsters; 51 subjects completed the study with an initial mean age of 54. There were some outcomes that were likely unexpected; for example, waist circumference did not change between the experimental group and control group over the five years. There was a significant decrease in body fat in the exercise group that explained the difference in body weight. Still, the control group lost about two pounds in five years while the exercise group lost about six pounds. That actually turns out to be a good thing, as I’ll explain a little later.

The Exercise Program

The high-intensity interval training was just as advertised: intense. It included a 10-minute warm up, followed by four 4-minute intervals at 90% of maximum heart rate (HRMax) interspersed with 3 minutes of active recovery. They finished with a 5-minute cooldown. They used percentage of HRMax as assessed in the exercise test, because that’s an intense level. The focus is on the 4 minutes but those 4 are brutal. You do get to rest, but then you have to do it over again, and that’s a significant challenge to the cardiovascular system. As people got fitter, the intensity would be changed to sustain the 90% level.

What surprised me was that there was no organized exercise activity in the other eight months of the year; they just kept track of activity levels using the activity monitors. There were no differences between the control group and the exercise group in the eight months with no organized activity. That’s interesting.

Most Variables Didn’t Change

This probably surprised the researchers, but it was a desirable outcome. There were no significant differences in body fat, waist circumference, BMI, or overall percentage of body fat. While the subjects probably would have liked to have lost more weight, the fact that they didn’t shows that the changes that occurred in the risk factors for cardiovascular disease, such as high blood pressure and low HDL cholesterol as well as a lower insulin levels, showed that the difference was the actual exercise program itself. The differences in distribution of nutrients in the diet and in the total caloric intake were insignificant. As I mentioned earlier, the number of steps per day and other activities were still even. That means, again, the changes could be attributed to the exercise program alone.

The Bottom Line

What is abundantly clear is that if you really want to reduce medications, you have to pay the price by changing your lifestyle. In this study they focused on one variable: exercise. If you add a change in dietary intake, and or a change in the distribution nutrients, you may get even more benefits. But for me, it answers the question that I started with. You want to reduce medications? Change your lifestyle.

Is it worth it? That’s your call. But that’s what Aging with a Vengeance is all about.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

Can You Reduce Your Medications?

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One of the questions that I get asked frequently goes something like this: “Dr. Chet, how can I reduce the medications I’m taking?” Along with that question is, “I don’t want to have to take medications for blood pressure or cholesterol or diabetes. What can I do?” As we proceed with a focus on Aging with a Vengeance, a recently published study illustrated at least a partial answer to these questions.

Researchers in Spain recruited 64 subjects for an exercise program. The exercise program was a high-intensity interval training (HIIT) program, three days a week, that ran for four months under staff supervision. The rest of the year these subjects were given activity monitors that automatically uploaded data on activity, sleep, etc. The researchers also took a variety of blood samples for testing metabolic variables, tested the subjects’ fitness levels, assessed anthropomorphic measures such as body weight and waist circumference, and recorded medications related to blood pressure, cholesterol, triglycerides, and blood sugars. The subjects were retested after two years and again after five years.

Over the period of five years, an amazing 51 subjects completed the exercise sessions and all the testing required. That, in and of itself, is remarkable—I’ve done this type of study, and holding on to the subjects is one of the main challenges.

The primary question was answered: those who exercised as the study required took fewer medications for blood pressure, cholesterol, and blood sugar control. As you might expect, that isn’t the entire story, so we’ll wrap this up on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: MSSE. 2021. 53(7):1319-1325.

COVID-19 Attacks the Whole Body

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Our look at diseases associated with COVID-19 continues in this pre-4th of July memo. Let’s turn to diabetes. We know, based on prior reports, that people with type 2 diabetes as well as other comorbidities are susceptible to getting the worst symptoms of COVID-19. But now, there are also some reports that COVID-19 infections may cause diabetes; people diagnosed with COVID-19 with minor symptoms have developed type 1 diabetes later.

How could that happen? The first way may be a direct attack on the pancreas because it also contains many ACE2 receptors. Or it may be that as the virus stays in the body, it triggers an autoimmune response. Or it may somehow stimulate other dormant viruses due to the inflammation and immune response.

One of those is the Epstein-Barr virus; almost 90% of us have been exposed to it. Epstein-Barr impacts the nervous system in a significant way. Perhaps the challenge to the immune system somehow triggers the activation of Epstein-Barr to cause neurological dysfunction from mild to severe.

In doing the background research for these Memos, I found that scientists are looking at every organ for potential consequences of the COVID-19 virus infection. We already knew of cardiovascular problems as well as kidney damage; lung damage was significant whether the patient was on a ventilator or not. The impact on blood vessels, which are full of ACE2 receptors, are the root cause of many of the problems. With the loss of taste and smell, it may be that the virus causes the death of enough of those organelles that we are permanently impacted. We’re learning some patients develop problems in their brains such as strokes, psychosis, and altered mental state, and we’ll discover more conditions that are impacted by the virus as time goes on. And we haven’t even begun to discuss the microbiome.

The Bottom Line

As I wrote several weeks ago, I don’t want you to fear this virus but you’d better respect it. That means you do your best to avoid getting it and avoid spreading it.

This is the beginning of the major holiday of the summer. Being restricted in what we can do and where we can go has worn on people, perhaps even you. So let me leave you with two thoughts.

First, if getting into a pool is part of your holiday plans, go ahead. The chlorine in a well-maintained pool or hot tub will kill the virus and sunshine helps, so have some fun; but if you’re just socializing while wet and not social distancing, wear a mask.

Second, I’ll finish where I began this series: with wearing a mask in public. You don’t have to like it. Who does? Science clearly shows it reduces the risk of catching or spreading the virus which, as we’ve seen, has far more implications then just a little fever and cough. So if you’re going into public places, do what I do and wear the damn mask. Please.

What are you prepared to do today?

        Dr. Chet

Reference: Nature. 2020. doi: 10.1038/d41586-020-01891-8.

Does Fiber Improve Your Microbiome?

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Now let’s look at the results of increasing dietary fiber for people with diabetes. Researchers recruited over 50 type 2 diabetics (T2D) for a 12-week study. The control group was given standard recommendations for a healthy diabetic diet. All current medications were maintained and both groups received acarbose, a starch blocker. The experimental group was put on a diet of prepared high-fiber foods and a diet higher in vegetables and fruits. Stool samples were collected periodically to assess the impact of the diet on the microbiome.

While the variables were straightforward, the analytic techniques were extraordinarily complex. It’s easy to say you want to examine the microbiome, but that’s not simple to do with thousands of types of microbes to analyze. Several types of bacteria from different species responded to the increase in fiber: bacteria that produced short-chain fatty acids (SCFA). The SCFAs are important because they feed the cells in the gut that do all the work during digestion and absorption.

HbA1c levels decreased faster and in a higher percentage of subjects in the experimental group than the control group. The fiber group also lost more weight and their blood lipids improved more than controls.

This was a small study, limited by the complexity of analyzing the microbiome, but the improvement in T2D simply due to an increase in fiber from foods is important. One more thing: this was a Chinese study, so typical high fiber foods from China were used. Is that important? We’ll find out Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: Science. 2018. 359:1151–1156.

Health Headline: Ketogenic Diet and Type 1 Diabetes

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Researchers wanted to examine the blood sugar control of type 1 diabetics who use a very low carbohydrate, high-protein, moderate fat ketogenic diet. The diet was developed by Dr. Richard Bernstein, himself a type 1 diabetic. They used a unique study design: they requested volunteers from a Facebook group of children and adults who adhere to the Bernstein Diet. Over 300 volunteers completed an online survey about their diagnosis and diet. The diagnosis of type 1 diabetes was confirmed from medical records from a follow-up survey of medical staff.

This was a rigid ketogenic diet with no more than 30 grams of carbohydrate allowed per day. The average intake was 36 grams carbohydrate per day. The better the control of carbohydrate intake, the better the HbA1c score, with a mean of 5.7%. Remember, these were type 1 diabetics; there are many type 2 diabetics who don’t control their HbA1c that well. I think this study illustrated the potential of nutrition in affecting a disease system. One interesting aside was the healthcare professionals treating the patients seemed indifferent to the dietary approach regardless of the results.

Headline worthy? Yes, in context. Close to half the subjects did not provide access to medical personnel so the researchers relied on the initial subject surveys for information. They also had no access to any dietary records to confirm the diet. Still this was a unique way to use social media to gather information. The study has to be confirmed using traditional research design to assess the variables. But this approach examined people who live this diet on their own or with their children. That can provide insights that might be missed if the study were conceived by a group of research professionals discussing the question around a table.

What are you prepared to do today?

Dr. Chet

 

Reference: Pediatrics. 2018. doi: 10.1542/peds.2017-3349.