Treating overweight and type 2 diabetes through natural dieting
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Treating Overweight and Type 2 Diabetes through Natural Dieting. Mary T. Stewart BSN, MN, APRN (Family Practice) Coordinator of Women’s Health Clinic and co-leader of Weight-loss Group, Marian Clinic, Topeka, KS Foundation for Prevention

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Treating overweight and type 2 diabetes through natural dieting

Treating OverweightandType 2 DiabetesthroughNatural Dieting

Mary T. Stewart BSN, MN, APRN (Family Practice)

  • Coordinator of Women’s Health Clinic and co-leader of Weight-loss Group, Marian Clinic, Topeka, KS

  • Foundation for Prevention

  • Preceptor for Advanced Practice Nursing, Washburn University and Fort Hays State University

  • Certified Practitioner, Creighton University Model of Fertility Care & Family Planning

    [email protected]

Irving A. Cohen, MD, MPH

Fellow of the American College of Preventive Medicine

Board-certification in Preventive Medicine & Public Health

Preventive Medicine Associates, Topeka, KS

Foundation for Prevention

Volunteer Physician and co-leader of Weight-loss Group, Marian Clinic, Topeka, KS

[email protected]


Schedule agenda

Schedule & Agenda

Introduction & Overview

Obesity & Diabetes Epidemics

Natural Cycles of energy use and storage and Metabolic Pathways during these cycles

Role of the liver, pancreas and brain in energy use and appetite regulation

Changes in last 150 years and last 30 years (Transportation, adulteration, fads, bad science)

Physical findings and appropriate laboratory use

Metabolic syndrome & “pre-diabetes”

Insulin resistance & cardiovascular risk

Polycystic Ovary Disorder, fertility & menstrual irregularities

Reversal of problems

Early detection versus patient resistance including the power of an exemplar role

Realistic goal-setting versus BMI reliance

Individual , group, materials, e-learning, & group each have value

Reinforcing good outcomes & dealing with problems or relapses

Issues with special situations

Limited resources, cultural & ethnic issues, family & LGBT conflicts


That was me before

“That was me before”

All photos used with patient permission.


Treating overweight and type 2 diabetes through natural dieting

The Obesity Epidemic is a Worldwide Epidemic

  • Worldwide –Problems in both industrialized and rapidly developing areas

  • USA – About2 out of 3adults are now overweight


Overweight has been associated with

Overweighthas been associated with:

Sudden Death

Early Death

Depression

Fatigue

Osteoarthritis

Heart Disease

Cancer

Kidney Disease

Diabetes

High Blood Pressure

Respiratory Problems

Snoring

Sleep Apnea

Asthma

Gastric Reflux

Menstrual Problems

Infertility

Sexual Problems

Premature dementia

Skin Problems

…and many more

Obesity, Volume 17, Sep 2009


Nature is seasonal

Nature is Seasonal


Nature is seasonal1

Nature is seasonal

and so is our food supply !


Humans and animals are well adapted to this seasonal food supply

Humans and animals are well-adapted to this seasonal food supply

with a flexible and balanced energy storage and use system.


But modern patterns of food storage distribution and processing have interrupted this natural cycle

but, modern patterns of food storage, distribution and processing have interrupted this natural cycle


Most cells are equally capable of utilizing either fat or sugar for energy

Long-Term Storage

months

Triglycerides

Ketones

ketone energy pathway

Most cells are equally capable of utilizing either fat or sugar for energy.

Short-Term Storage

days

Carbohydrates

Glucose

glucose energy pathway

ATP ADP

Work


Energy balance

Energy Balance

energy

eaten

energy

used

Even kids know, losing weight means eating less than you burn


This simple answer works if confined

This simple answer works (if confined)!

energy

eaten

energy

used


Treating overweight and type 2 diabetes through natural dieting

but, will it work without confinement?


Food mixture hidden additives misunderstanding emotions mood medications

Food mixtureHidden AdditivesMisunderstandingEmotions & MoodMedications

Hunger

&

Overeating


Dieting basis

  • Truly Ketogenic

  • Clear stored Glycogen first

  • Brain must switch to Ketones

  • Sufficient supply, if obese

  • GABA increase calms CNS

  • Increased satiety

  • Infrequent feeding acceptable

  • Positive outlook with success

  • FRAGILE – increased glucose triggers old sugar cravings

Dieting Basis

Carbohydrate-Focused

Difficult to reduce intake

Rising and falling glucose level leads to cycle of Anxiety& Hunger vs. Satiety & Comfort

Frequent feedings

Gluconeogenesis to burn fat

May catabolize muscle

Pattern of diet failure reinforces negative self-image


Treating overweight and type 2 diabetes through natural dieting

Is ketosis good or bad?

  • Ketosis indicates efficient fat burning,if dieting.

  • Ketones are acidic, so initially expect mild metabolic acidosis, which the body will adjust with increased buffering

  • Glucose should be in normal range

  • Ketosis indicates energy imbalance, if not dieting.

  • Poorly controlled diabetes with hyperglycemia & hyperosmolarity(starving in the midst of plenty).

  • Abnormal energy drain (occult cancer).

  • Malnutrition


Treating overweight and type 2 diabetes through natural dieting

Clinical uses of ketosis

KetogenicDiets

from Paoli et al, Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets, European Journal of Clinical Nutrition (2013) 67, 789-796


Ketogenic ratio

Ketogenic Ratio

Ketogenic Ratio (or KR) calculates whether a diet will cause ketosis, once carbohydrate stores are depleted.

KR= Ketogenic Anti-Ketogenic

TotalKetogenic Ratio (or TKR)takes the use of stored energy into account.

It is calculated using the formula:

from Cohen IA. A method for determining total ketogenic ratio (TKR) for evaluating the ketogenic property of a weight- reduction diets, Medical Hypotheses, Vol. 73, pp 377-81, 2009.

You will not need to use this, just know it exists.


Regulating energy

Regulating Energy

Pancreas hormones to regulate energy metabolism.

Liverconversions to

needed form

Braincontrols & reacts

hunger, stress, appetite

Triglycerides

Ketones

Glucose

Insulin

Glucagon

Anxiogenic

Anxiolytic


Complementary roles of insulin vs glucagon

Complementary Roles ofInsulin vs. Glucagon

from Diabetes Recovery, Cohen, 2010


Timelines 1

Timelines 1

  • circa

  • 700 BC Sugar first extracted in India, obesity and “Prameha” (T2DM) follows

  • 800s Sugar knowledge spreads through Mediterranean.

  • 1500s European nations bring African slavery to Americas for mass sugar cultivation

  • mid-1800s Steam power for transportation lowers costs of food, while invention of canning enhances variety. Hydrogenation & margarine invented.

  • late-1800s Sugar beet introduction and mechanized harvesting reduce costs further.

  • early-1900s MSG isolated in Japan, use spreads in Asia. Unknown in US.


Timelines 2

Timelines 2

  • circa

  • 1950s-60s MSG introduced to U.S., usage increases. Concern over CVD leads to wrong conclusions regarding etiology. Fear of saturated fats leads manufacturers to capitalize on margarine fallacy.

  • 1970s-80s Bad science leads government to anti-fat campaign, which proves effective in changing beliefs and behaviors. Tobacco companies take control of U.S. food industry. Food companies charge extra for “healthier” faux foods, manipulate tastes and appetites with chemical flavor enhancers.


Timelines 3

A Perfect Storm

of bad events.

Timelines 3

  • circa

  • 1990s to present day

    • Overweight, obesity, and type 2 diabetes prevalence more than doubles.

    • Portion sizes explode.

    • Manufacturers learn how to hide presence of additives.

    • Government pours more resources into the same programs that caused the problems.

    • Use of pharmacological response to preventable problems explodes.

    • Media “reality shows” focus on blaming the victims.


Time for a short break

Time for a short break?


Early problem detection

Early Problem Detection

  • Always have a high index of suspicion

  • Listen closely to your patient, she will often tell you the diagnosis

    • Chief Complaint

    • History & Review of Systems

    • Physical Exam

    • Labs


Early problem detection1

Early Problem Detection

Chief Complaint

Is it related to or aggravated by nutrition, weight, depression, inflammation, etc.?


Early problem detection2

Early Problem Detection

History & Review of Systems

  • Is there a family history of overweight, diabetes, or cardiovascular disease?

  • Does she have a history of gestational diabetes or high-birthweight children?

  • Thinks she has hypoglycemic episodes? Rapid mood swings? Mid-morning hunger? Carbohydrate cravings?

  • Menstrual irregularities, pelvic pain, infertility, polycystic ovary?

  • Told she was “pre-diabetic”?

  • History of GERD, sleep apnea, or asthma?

  • Weight history, including at HSG & prior to 1st pregnancy. Prior attempts, “dream weight”?


Early problem detection3

Early Problem Detection

Physical Exam

Height & Weight, but do not rely on BMI(Statistical tool, some use in screening but many reasons for false negatives and false positives)

Waist measurement (metabolic syndrome >35” in women, >40” in men but ethnic differences)

Percentage Body Fatcaliper (1 to 7 point) and electronic (2 or 4-point)

Lower-extremity vibratory sensation128 hz tuning fork

Bimanual Pelvic Examif indicated by menstrual complaint


Early problem detection4

Early Problem Detection

Labs

a1c

C-reactive protein (High Sensitivity)

Chemistry profile

Lipid profile

TSH (with reflex T4)

consider vitamin D if symptomatic

myofascial pain, fibromyalgia, depression, chronic infections

consider fasting insulin level, if needed


Treating overweight and type 2 diabetes through natural dieting

Progression of type 2 diabetes

excess energy

intake

temporarily higher glucose level

more insulin produced

a vicious loop

more insulin produced

resistance to insulin develops

higher glucose level

insulin insufficiency

consistently higher glucose level


Treating overweight and type 2 diabetes through natural dieting

Early detection of abnormality by lab testsWhich should you choose?

a1c

excess energy

intake

temporarily high glucose levels

more insulin produced

a vicious loop

gtt

more insulin produced

resistance to insulin develops

higher glucose level

fbs

consistently higher glucose level

insulin insufficiency


Treating overweight and type 2 diabetes through natural dieting

Early Problem Detection

Incidence rate for CVD, CHD, stroke, and HF

One study with known diabetics showing increased risk

A1c and risk

from Wang H, et al. Hemoglobin A1c, Fasting Glucose, and Cardiovascular Risk in a Population With High Prevalence of Diabetes: The Strong Heart Study, Diabetes Care 2011;34:1952-1958


Treating overweight and type 2 diabetes through natural dieting

Early Problem Detection

but a study of individuals without diagnosed diabetes shows the same pattern of increased risk

A1c and risk

from Selvin et al, Glycated Hemoglobin, Diabetes, and Cardiovascular Risk in Nondiabetic Adults, N Engl J Med. 2010 March 4; 362(9)


Treating overweight and type 2 diabetes through natural dieting

“Diabetes” is part of a continuum

Treat the patient, not the definition!

Diabetes

Gestational Diabetes

pre-diabetes

Polycystic Ovary Syndrome

Metabolic Syndrome

Insulin Resistance

illustrative, not to scale


Treating overweight and type 2 diabetes through natural dieting

“Diabetes” is part of a continuum

Treat the patient, not the definition!

Energy excess

High glucose

High insulin

Fat Creation & storage

Cancer Risk

Overweight

Obesity

Cardiovascular Risk

Diabetic

Insulin Resistance

PCOS

illustrative, not to scale


Treating overweight and type 2 diabetes through natural dieting

PCOS

  • Overweight

  • Amenorrhea

  • Irregular Menses

  • Menstrual pain

  • Ovarian tenderness

  • Infertility

  • Androgen Excess

  • Hirsutism

  • Acne

  • Hormonal imbalances

from Liepa et al. Polycystic Ovary Syndrome (PCOS) and other Androgen-Excess Related Conditions: Can changes in Dietary Intake Make a Difference?, Nutr Clin Pract 2008 23:63


Treating overweight and type 2 diabetes through natural dieting

PCOS Treatment

  • Hormones (BCP)

    • Deals with symptoms, not underlying problem

  • Metformin

    • Improves insulin resistance

  • Weight Loss

    • Improves underlying causes

    • Improvement is not from the weight-loss itself, but rather the dietary change bringing about the loss

    • ketogenic better than low-glycemic index


Treating overweight and type 2 diabetes through natural dieting

Effective Treatment of

overweight, T2DM, PCOS

  • 1. SCREEN, SCREEN, SCREEN

    • Prevention or early intervention puts the patient first

    • BMI is only a first step, neither rules in or rules out problems

  • Be positive about intervention

    • Cite examples of change, respecting confidentiality

    • Use your own story, if it is appropriate

    • Use narrative, rather than statistics

  • Be a knowledgeable & positive resource

    • Available for questions and reassurance


Treating overweight and type 2 diabetes through natural dieting

Effective Treatment of

overweight, T2DM, PCOS

  • Use an effective ketogenic diet

    • We use 60 grams fat, 40 grams protein, 10 grams carbohydrate, MSG avoidance

    • Partial fast initiation, usually 2 – 3 days, urinary test for ketosis

    • If diabetic and on medications, must:

      • be closely supervised by mid-level practitioner or M.D.

      • Have a written contract agreeing to self-monitoring QID (AM & 2 hr PP)

      • Strict plan for stopping or reducing medications

      • Close & frequent communication, especially 1st week


Treating overweight and type 2 diabetes through natural dieting

Effective Treatment of

overweight, T2DM, PCOS

  • Keep goals realistic

    • Use % body fat with age & sex adjustment, not BMI to set target weight

    • Factor in personal weight history & desires

  • Provide a wide variety of substitute food recipes and encourage consistency and compliance.

  • Possible supplements, OTC, inexpensive, recommend but do NOT sell.

    • Multivitamin + mineral OR prenatal for ALL

    • Psyllium Fiber (SF) for ALL

    • Vitamin D3 if deficient

    • Mg or Mg+Ca+Mg if muscle cramps or hair loss

    • Folate if hair loss

    • Chromium (pancreatic co-factor)

    • Carnitine (stimulates ketosis)

    • DHEA (central obesity, libido) CAUTION –Testosterone

    • Baking soda (quicker buffering)


Treating overweight and type 2 diabetes through natural dieting

Effective Treatment of

overweight, T2DM, PCOS

  • Require self-monitoring and check diary at frequent meetings.

    • Patient-centered personal partial goals

    • “Turkey Awards”

  • Form support group, whether billable or not.

  • Accept relapses, bumps in the road, remain positive about progress made.

  • Methods may include:

    • 1 on 1

    • Group

    • Lectures

    • E-learning

    • Bibliotherapy

    • Buddy or mentor pairings

    • Outside support groups


Treating overweight and type 2 diabetes through natural dieting

Special Issues

  • Language and Cultural Barriers

    • Translators, native language materials, family

    • Cultural barriers may exist in many forms, be flexible

  • Resource Availability

    • Know local sources, prices, make recommendations

    • Foods may be higher price, but offset by smaller portions and less junk snacks

    • Provide advice on traveling and family events

  • Relationships and Support

    • Some may be in destructive relationships, where self-improvement of any sort is threatening

    • Some may be unaccustomed to attention from others when looks change. Both positive and negative aspects!

    • Many will be in supportive relationships, but weight can be a delicate issue

    • Co-workers and “friends” may be supportive or saboteurs

    • LGBT issues are exactly the same, group should be supportive when they understand that


Treating overweight and type 2 diabetes through natural dieting

  • ?

Questions

and

Discussion

[email protected] [email protected]


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