Chapter
12: Weight Loss--If You're Overweight /
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Tools for Weight Loss
Because of the
diversity of the population of the United States,
and the likelihood of there being more than one genetic
mechanism that causes us to conserve body fat, there
may be many genetic mechanisms that result in obesity.
The most common overt cause of obesity is overeating
carbohydrate, usually over a period of years. Unfortunately,
this can be a very difficult type of obesity to treat.
If you're overweight, you're
probably unhappy with your appearance, and no less
with your high blood sugars. Perhaps in the past you've
tried to follow a restricted diet, without success.
Generally, overeating follows two patterns, and frequently
they overlap. First is overeating at meals. Second
is normal eating at mealtime but with episodic binge
eating. Binge eating can be anything from nibbling
and snacking between meals to eating everything that
does not walk away. Many of the people who follow
our low-carbohydrate diet find that their carbohydrate
craving ceases almost immediately, possibly because
of a reduction in their serum insulin levels. The
addition of muscle-building exercise sometimes enhances
this effect. Unfortunately, these interventions don't
work for everyone.
Medications
If you're a compulsive overeater, if you just can't
stop yourself from eating, and are addicted to carbohydrate,
you may not be able to adhere to our diet without
some sort of medical intervention. Carbohydrate addiction
is just as real as drug addiction, and in the case
of the diabetic, it can have equally disastrous results.
(In actual fact, obesity kills more Americans annually
from its related complications than all drugs of abuse
combined, including alcohol.)
You need not despair of ever losing weight, however.
I have seen a number of "diet-proof" patients
over the years get their weight down and blood sugars
under control. Over the last several years, as medical
science has gained a much more sophisticated understanding
of the biological mechanisms that contribute to emotional
states such as hunger and mood, many relatively benign
medications have been successfully applied to the
treatment of compulsive overeating. There is no doubt
that when used properly, many appetite suppressants
are quite effective in helping people to lose weight.
If you simply cannot lose weight, discuss with your
physician medicines that may be of use to you. I have
used more than forty different medications with my
patients and have found many of them to be of great
value for treating carbohydrate addiction. Their proper
application, however, requires considerable specialized
knowledge.
Reducing Serum Insulin Levels
Another group of Type II diabetics has a common story:
"I was never fat until after my doctor started
me on insulin." Usually these people have been
following high-carbohydrate diets and so must have
large doses of insulin to effect a modicum of blood
sugar control.
Insulin, remember, is the principal fat-building hormone
of the body. Although a Type II diabetic may be resistant
to insulin-facilitated glucose transport (from blood
to tissues), that resistance doesn't diminish insulin's
capacity for fat-building. In other words, insulin
can be great at making you fat, even though it may
be inefficient at lowering your blood sugar. Since
excess insulin causes insulin resistance, the more
you take, the more you'll need, and the fatter you'll
get. This is not an argument against the use of insulin;
rather it supports our conclusion that high levels
of dietary carbohydrate—which, in turn, require large
amounts of insulin—make blood sugar control (and weight
reduction) unworkable.
I have witnessed, over and over, dramatic weight loss
and blood sugar improvement in people who have merely
been shown how to reduce their insulin doses and carbohydrate
intake.
Metformin, troglitazone, and similar agents, which
we will discuss in detail in Chapter 14, "Oral
Hypoglycemic Agents," can also be valuable tools
in weight loss. They work by making the body's tissues
more sensitive to injected or self-made insulin. As
it takes less insulin to accomplish our goal of blood
sugar normalization, you'll have less of this fat-building
hormone circulating in your body. I have patients
using these unique medications who are not diabetic,
and they work in a similar way: the body is more sensitive
to insulin, so it needs to produce less, and there
is, again, less of it present to build fat. One may
also have less of a sense of hunger, and less loss
of control.
Increasing Muscle Mass
All the above suggests what we have been advocating
all along—a low-carbohydrate diet. But what do you
do if this plus one of the above medications does
not result in weight loss? Another step is muscle-building
exercise (see next chapter). This is of value in weight
reduction for several reasons. Increasing lean body
weight (muscle mass) upgrades insulin sensitivity,
enhancing glucose transport and reducing insulin requirements
for blood sugar normalization. Lower insulin levels
facilitate loss of stored fat. Chemicals produced
during exercise (endorphins) tend to reduce appetite,
as do lower serum insulin levels. People who have
seen results from exercise tend to invest more effort
in looking even better (e.g., by not overeating, and
perhaps exercising more). They know it can be done.
How to Estimate Your Real
Food Requirements
Now suppose you
have been following our low-carbohydrate diet, have
been conscientiously "pumping iron" every
day, and are, in effect, "doing everything right."
What else can you do, if you have not lost weight?
Well, everyone has some level of caloric intake below
which they will lose weight. Unfortunately, the "standard"
formulas and tables commonly used by nutritionists
set forth caloric guidelines for theoretical individuals
of a certain age, height, and sex, but not for real
people like you. The only way to find out how much
food you need in order to maintain, gain, or lose
weight is by experiment. Here is an experimental plan
that your physician may find useful. This method usually
works, and without counting calories.
Begin by setting an initial target weight and a time
frame in which to achieve it. Using standard tables
of "ideal body weight" is of little value,
simply because they give a very wide target range.
This is because some people have more muscle and bone
mass for a given height than others. The high end
of the ideal weight for a given height on the Metropolitan
Life Insurance Company's table is 30 percent greater
than the low end for the same height.
Instead, estimate your target weight by looking in
the mirror after weighing yourself. (It pays to do
this in the presence of your health care provider,
because he/she probably has more experience in estimating
the weight of your body fat.) If you can grab handfuls
of fat at the underside of your upper arms, around
your thighs, around your waist, or over your belly,
it is pretty clear that your body is set for the next
famine. Your estimate at this point need not be terribly
precise, because as you lose weight your target weight
can be reestimated. Say, for example, that you weigh
200 pounds. You and your physician may agree that
a reasonable target would be 150 pounds. By the time
you reach 160 pounds, however, you may have lost your
visible excess fat—so settle for 160 pounds. Alternately,
if you still have fat around your belly when you get
down to 150 pounds, it won't hurt to shoot for 145
or 140 as your next target, before making another
visual evaluation. Gradually you home in on your eventual
target, using smaller and smaller steps.
Once your initial target weight has been agreed upon,
a time frame for losing the weight should be established.
Again, this need not be utterly precise. It's important,
however, not to "crash diet." This may cause
a "yo-yo" effect by slowing your metabolism
and making it difficult to keep off the lost bulk.
Bear in mind that if you starve yourself and lose
10 pounds without adequate dietary protein and an
accompanying exercise regimen, you may lose 5 pounds
of fat and 5 pounds of muscle. If you gain back that
10 pounds from eating carbohydrate and still are not
exercising, it may be 100 percent fat. After crash
dieting, once you've reached your target, you may
go right back to overeating. I like to have my patients
follow a gradual weight-reduction diet that matches
as closely as possible what they'll probably be eating
after the target has been reached. In other words,
once you reach your target, you stay on the same diet
you followed while losing weight. This way you've
gotten into the habit of eating a certain amount,
and you stick to this amount, more or less, for life.
To achieve this, weight loss must be gradual. If you
are targeted to lose 25 pounds or less, I suggest
a reduction of 1 pound per week. If you're heavier,
you may try for 2 pounds per week. If just cutting
the carbohydrate, as suggested in prior chapters,
results in a more rapid weight loss, don't worry—just
enjoy your luck. This has happened to a number of
my patients.
Weigh yourself once weekly—stripped, if possible,
on the same scale, and before breakfast. Pick a convenient
day, and weigh yourself on the same day each week
at the same time of day. It's counterproductive and
not very informative to weigh yourself more often.
Small, normal variations in body weight occur from
day to day and can be frustrating if you misinterpret
them. Generally speaking, you won't lose or gain a
pound of body fat in a day. Continue on your low-carbohydrate
diet, with enough protein foods to keep you comfortable.
Let's say that your goal is to lose 1 pound every
week. Weigh yourself after one week. If you've lost
the weight, don't change anything. If you haven't
lost the pound, reduce the protein at any one meal
by one-third. For example, if you've been eating 6
ounces of fish or meat at dinner, cut it to 4 ounces.
You can pick which meal to cut back at. Check your
weight one week later. If you have lost a pound, don't
change anything. If you haven't, cut the protein at
another meal by one-third. If you haven't lost the
pound in the subsequent week, cut the protein by one-third
in the one remaining meal. Keep doing this, week by
week, until you are losing at the target rate. Never
add back any protein that you have cut out even if
you subsequently lose 2 or 3 pounds in a week.
If you've managed to lose at least 1 pound weekly
for many weeks, but then your weight levels off, this
is a good time for your physician to prescribe the
special insulin resistance–lowering agents described
in Chapter 14. Alternately you can just start cutting
protein again. Continue this until you reach your
initial target or until your visual evaluation of
excess body fat tells you that further weight loss
isn't necessary. Most adults require at least 5 ounces
of high-quality protein daily to prevent certain forms
of malnutrition. It is therefore unwise to cut your
protein intake below this level. Some authorities
recommend double this amount. Once you've reached
your target weight, do not add back any food. You
will probably have to stay on approximately this diet
for many years, but you'll easily become accustomed
to it. If you required some of the appetite-reducing
medications mentioned earlier in the chapter, do not
discontinue them. About six months after you reach
your target weight, your physician may want to taper
off the medication(s) gradually. If you start eating
more than your final meal plan calls for, the medication(s)
will have to be tapered up again.
Reduce Diabetes Medications
While Cutting Protein or Losing Weight
While you're losing
weight, keep checking blood sugars at least 5 times
daily, at least two days a week. If they consistently
drop below your target value for even a few days,
advise your physician immediately. It will probably
be necessary to reduce the doses of any blood sugar–lowering
medications you may be taking. Keeping track of your
blood sugar levels as you lose weight and eat less
is essential for the prevention of dangerously low
blood sugar levels.
Increased Thrombotic Activity
During Weight Loss
During weight
loss, many people unknowingly experience increased
clumping of the small particles in the blood (platelets)
that form clots (thrombi). This can increase the risk
of heart attack or stroke. Your physician may therefore
want you to take an 80 mg enteric coated aspirin once
daily after a meal to reduce this tendency.
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