Treating Overweight and Type 2 Diabetes through Natural Dieting

1. 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 mstewart@marianclinic.org 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 drcohen@foundattionforprevention.org

2. 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

3. “That was me before” All photos used with patient permission.

4. The Obesity Epidemic is a Worldwide Epidemic • Worldwide –Problems in both industrialized and rapidly developing areas • USA – About2 out of 3adults are now overweight

5. 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

6. Nature is Seasonal

7. Nature is seasonal and so is our food supply !

8. Humans and animals are well-adapted to this seasonal food supply with a flexible and balanced energy storage and use system.

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

10. 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

11. Energy Balance energy eaten energy used Even kids know, losing weight means eating less than you burn

12. This simple answer works (if confined)! energy eaten energy used

13. but, will it work without confinement?

14. Food mixtureHidden AdditivesMisunderstandingEmotions & MoodMedications Hunger & Overeating

15. 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

16. 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

17. 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

18. 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.

19. Regulating Energy Pancreas hormones to regulate energy metabolism. Liverconversions to needed form Braincontrols & reacts hunger, stress, appetite Triglycerides Ketones Glucose Insulin Glucagon Anxiogenic Anxiolytic

20. Complementary Roles ofInsulin vs. Glucagon from Diabetes Recovery, Cohen, 2010

21. 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.

22. 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.

23. 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.

24. Time for a short break?

25. 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

26. Early Problem Detection Chief Complaint Is it related to or aggravated by nutrition, weight, depression, inflammation, etc.?

27. 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”?

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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)

34. “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

35. “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

36. 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

37. 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

38. 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

39. 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

40. 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)

41. 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

42. 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

43. ? Questions and Discussion drcohen@foundattionforprevention.org mstewart@marianclinic.org