Weight gain significantly elevates the risk of developing diseases like diabetes. However, the intricate relationship between weight, blood sugar, and insulin is often underestimated. Dr. Osama Hamdy, MD, Medical Director of the Obesity Clinical Program at Joslin Diabetes Center and author of "The Diabetes Breakthrough," emphasizes the complexity of this cycle. Understanding this complex interplay is crucial for interrupting the cycle and achieving sustainable weight loss, particularly for individuals with type 2 diabetes, where approximately 80% are overweight or obese.
Understanding the Vicious Cycle: Insulin Resistance and Weight Gain
Every time you eat, your pancreas produces insulin, a hormone that enables your body to utilize the energy from food. Insulin unlocks your cells, facilitating the movement of glucose (sugar) inside where it is used for fuel. The problem arises with insulin resistance, where cells become less responsive to insulin. Weight gain, particularly visceral fat accumulation around abdominal organs, contributes to insulin resistance. Visceral fat releases inflammatory chemicals that impair the cells' response to insulin.
David G. Marrero, PhD, President of Health Care and Education at the American Diabetes Association, illustrates this with an analogy: "Fill the trunk with 500 pounds of gravel and it's harder to run. It needs more gas and it wears out the engine to get the same level of performance." Obesity, in this case, is like the gravel weighing down the car. "Now think of insulin as the gas line between the fuel tank and the engine. Insulin resistance squeezes it, so when you need more fuel, it's harder to get."
When insulin-resistant cells struggle to absorb glucose from the blood, sugar levels rise. Over time, this can lead to diabetes, which can damage blood vessels and further promote weight gain. Elevated blood glucose signals the pancreas to produce more insulin. However, excess insulin encourages the body to store extra sugar as fat, perpetuating the cycle. Shedding pounds can slow down the disease. "You gain more efficiency with every pound of gravel you take out of the trunk," Marrero says.
Four Strategies for Fighting Back
To combat this cycle, Dr. Hamdy and other experts suggest a multi-faceted approach:
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1. Eat Less, But Eat Often
For individuals with diabetes, especially those taking insulin, maintaining stable blood sugar levels is crucial. Completely eliminating snacks to reduce calorie intake is often not advisable. However, frequent eating doesn't necessitate consuming larger quantities. Marrero emphasizes that "You don't need an extraordinarily large number of calories to function, even with diabetes. Eating small portions throughout the day is a good way to cut calories while keeping your blood sugar steady." Planning snacks in advance is essential, especially when on the go. Jessica Crandall, RDN, suggests options like 1 ounce of turkey jerky with whole-wheat crackers or a piece of fruit.
2. Think Balance, Not Calories
Crandall advises, "you need to be like the three bears and get the right mix of carbs, protein and fiber to keep blood sugar balanced." Focusing solely on calories can hinder weight loss. Protein is essential for muscle support and metabolism, fat aids in vitamin absorption, and carbohydrates provide energy. Aim for approximately 30 to 45 grams of carbs, 20 grams of protein, and 7 to 10 grams of fiber per meal. Crandall suggests a breakfast of scrambled eggs (or an egg substitute), diced sweet potato, black beans, and salsa, or Greek yogurt with sliced fruit and a handful of almonds.
3. Get Moving
Dr. Hamdy explains that exercise facilitates glucose uptake by muscles without requiring insulin and enhances insulin sensitivity over time. Individuals with diabetes should gradually increase their activity levels, aiming for at least 175 minutes of exercise per week, broken into short intervals throughout the day. Strength training is also crucial to counteract muscle loss, which can be accelerated by diabetes. Preserving or increasing muscle mass boosts calorie expenditure, even at rest.
4. Chill Out
Stress triggers the body's fight-or-flight response, leading to reduced insulin production and increased glucose release, providing fuel for potential threats. While beneficial in acute situations, this response is counterproductive when dealing with chronic, modern-day stressors. Marrero advises reducing stress and developing healthy coping mechanisms that don't involve food or alcohol.
Dr. Osama Hamdy's Contributions to Diabetes and Obesity Research
Dr. Osama Hamdy is a leading expert in obesity, nutrition, and diabetes technology. He serves as a Senior Endocrinologist and Medical Director of the Joslin Obesity Clinical Program, Director of International Medical Affairs at Joslin Diabetes Center, and Associate Professor of Medicine at Harvard Medical School.
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Dr. Hamdy's research has demonstrated that a modest 7% weight loss in obese patients, with or without diabetes, significantly improves vascular endothelial function, insulin sensitivity, and markers of inflammation. He was also a co-investigator in the landmark Diabetes Prevention Program and the Look AHEAD Study.
In 2005, Dr. Hamdy established the Weight Achievement and Intensive Treatment (Why WAIT) program, which has been implemented nationally and internationally. He also founded the Diabetes Remission Outcome Program (DROP), which aims to help newly diagnosed patients with diabetes achieve remission and discontinue medication within five years. Dr. Hamdy co-chaired the task force responsible for developing the global transcultural Diabetes Nutrition Algorithm (tDNA).
Dr. Hamdy joined Joslin Diabetes Center in 1998, where he founded the obesity clinical program and restructured the inpatient diabetes program. His contributions have been recognized with the 2015 Michaela Modan Award from the American Diabetes Association and the Compassionate Caregiver Award from the Kenneth Schwartz Center. Dr. Hamdy has authored over 150 peer-reviewed articles, reviews, and book chapters, including the Harvard Health Publication "The Diabetes Breakthrough."
The Why WAIT Program: A 5-Year Study on Long-Term Weight Loss
A 5-year study reveals that a properly constructed diet, along with exercise aimed at muscle maintenance, can achieve long-term weight loss results. Dr. Hamdy has presented data from this study, challenging conventional wisdom about the futility of diet and exercise in managing type 2 diabetes.
The study followed 129 patients who participated in the 12-week Weight Achievement and Intensive Treatment (Why WAIT) program at the Joslin Diabetes Center. The results indicated that a majority of patients maintained significant weight loss and enjoyed significant health benefits over the five-year period.
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The study demonstrated that sustained weight loss could reduce the burden of diabetes more effectively than previously believed. Patients who maintained a 7% or greater weight loss after one year were more likely to maintain their weight loss for five years and achieve good diabetes control, as reflected by reductions in glycated hemoglobin (A1C) levels.
Patients diagnosed with T2DM less than 5 years before the study began and who consistently maintained A1C levels below 7.5% with oral medication alone experienced particularly positive outcomes. Many of these patients achieved partial or complete remission from diabetes.
A randomized controlled study comparing the Why WAIT program to bariatric surgery (gastric banding) showed no significant difference in diabetes control after one year. However, the Why WAIT group exhibited greater improvements in quality of life, particularly in mental health.
Dr. Hamdy emphasizes that diabetes research should prioritize addressing the underlying cause of T2DM, which is obesity, rather than solely focusing on managing symptoms with medication. He advocates for increased research funding for weight-loss studies and encourages clinicians to prioritize lifestyle modification as a primary treatment approach for T2DM patients.
Intensity and Key Features of the Why WAIT Intervention
Participants in the Why WAIT study underwent an intensive 12-week lifestyle intervention program that included a structured diet, regular exercise, cognitive therapy, group counseling, and medication adjustment. The subsequent 5-year study period involved periodic check-ups, medication adjustments, and routine care.
The study design addressed the limitations of previous studies by systematically adjusting medication levels based on patient response to the study regimen. By the end of the Why WAIT program, patients were using approximately half as much medication as they were before the study began, resulting in an average annual cost savings of $561 per year. The study also incorporated a muscle-maintenance program that included strength training and a protein-rich diet to minimize muscle loss during weight loss.
Men in the study consumed 1800 calories per day, while women consumed 1500 calories per day. Protein consumption was individualized based on body weight, with participants receiving 1.5 to 2 grams of daily protein per kilogram of baseline body weight. The diet also limited total carbohydrate consumption to 40% to 45%, emphasizing low glycemic index carbohydrates and fiber.
The exercise program included a mix of aerobic exercise, stretching, and strength training to prevent muscle loss. Patients gradually increased their exercise to 300 minutes per week by the end of the 12 weeks.
The initial regimen resulted in an average weight loss of 23.8 pounds, or 9.7% of body weight. Body fat content and percentage decreased significantly, while the ratio of lean muscle mass to fat mass increased, indicating successful preservation of lean muscle mass.
Long-Term Outcomes and Benefits of the Why WAIT Program
The study categorized participants into two groups: Group A, those who failed to remain at least 7% below baseline body weight for a full year, and Group B, those who did. The average 5-year weight loss for Group A members was 8.4 pounds (3.5%), while the average 5-year weight loss for Group B members was 23.1 pounds (9.0%).
While the weight loss had limited impact on simple health metrics, improvements in lipid profiles were significant and sustained for the full 5 years, even among patients who regained weight. Although initial declines in blood pressure were reversed over time, patients in Group B maintained stable A1C levels while taking fewer medications.
Dr. Hamdy emphasizes that halting or reversing the progression of diabetes is a significant achievement in disease management. The study demonstrated that weight reduction led to a dramatic increase in insulin sensitivity and improved overall health. Healthcare costs for study patients decreased by an average of 27%, while costs associated with diabetes care fell by 44%.
Key Components of the Why WAIT Program
The Why WAIT program combines existing knowledge and strategies to promote long-term lifestyle changes. Key components include:
- Daily weigh-ins
- Meal replacements
- Brief spurts of exercise throughout the day
- Medication adjustments
Dr. Hamdy believes that the program's success lies in its logical combination of diet, exercise, and counseling strategies.
Addressing Misconceptions and Promoting Lifestyle Modification
Dr. Hamdy argues that the focus of diabetes research and treatment has been excessively centered on controlling blood sugar with medication, neglecting the underlying cause of obesity. He advocates for a shift in priorities towards weight control and lifestyle modification.
He also criticizes the influence of flawed studies and nutritional guidelines that have contributed to the obesity epidemic. He emphasizes the importance of prioritizing protein consumption over sugar and starch to promote satiety and prevent muscle loss.
Medical Nutrition Therapy and Macronutrient Composition
Medical nutrition therapy plays a crucial role in diabetes management. There is growing evidence that a modest increase in dietary protein intake above the current recommendation is a valid option toward better diabetes control, weight reduction, and improvement in blood pressure, lipid profile, and markers of inflammation.
Increasing the absolute protein intake to 1.5-2 g/kg (or 20-30% of total caloric intake) during weight reduction has been suggested for overweight and obese patients with type 2 diabetes and normal kidney function. Increased protein intake does not increase plasma glucose, but increases the insulin response and results in a significant reduction in hemoglobin A(1c). In addition, a higher dietary protein intake reduces hunger, improves satiety, increases thermogenesis, and limits lean muscle mass loss during weight reduction using a reduced calorie diet and increased physical activity.
It is preferable to calculate protein intake for patients with diabetes as grams per kilogram of body weight and not as a fixed percentage of total energy intake to avoid protein malnutrition when a hypocaloric diet is used. A protein intake of 0.8-1 g/kg should be recommended only for patients with diabetes and chronic kidney disease. Other patients with diabetes should not reduce protein intake to less than 1 g/kg of body weight.