~Diabetes, Part 4 - Obesity, Hyperinsulinemia, and Diabetes
HOW IS OBESITY LINKED TO HYPERINSULINEMIA AND DIABETES?
The Centers for Disease Control and Prevention reported that extra pounds and inactivity are to blame for hundreds of thousands of premature deaths in the United States annually. As girth increases, the chance of developing some form of ill health dramatically increases, including the risk for diabetes. At least 10 million overweight Americans could sharply cut their risk of developing diabetes by making relatively simple lifestyle changes, e.g., altering eating habits (restricting calories to 1200-1800 a day) and introducing exercise into their daily regime. Walking should never be discredited as a viable form of exercise; as little as 30 minutes of walking a day can dramatically improve the plight of prediabetic and diabetic patients (Cafazzo 2001; Blake 2002). (Read the section entitled Exercise: Helpful in Blood Glucose Control in this protocol.)
- Carbohydrate Digestion and Absorption
- Gylcemic Index and Dietary Recommendation
The Diabetes Prevention Program (a 3-year study) was the first large-scale study to show that losing weight and exercising can effectively delay diabetes. A study reported in the New England Journal of Medicine, involving 84,041 nondiabetic female nurses tracked from 1980-1996, substantiated earlier findings. During the 16-year follow-up, 3300 new cases of Type II diabetes were documented. Obesity was the single most important predictor of diabetes, but a lack of exercise, poor diet, and current smoking also contributed to the risk. The researchers concluded that the vast majority of cases of Type II diabetes (about 90%) could be prevented by the adoption of a healthier lifestyle (Hu et al. 2001).
It appears not to be a fluke that 50-90% of all people with Type II diabetes are overweight. According to Dan Lukaczer, N.D., obesity and chronic hyperinsulinemia induce insulin resistance in peripheral tissues. Chronic hyperinsulinemia (in turn) is a predictor of obesity. The Tulane National Center for Cardiovascular Health has determined that individuals with consistently elevated insulin levels (versus those with normal insulin levels) had a 36-fold increase in the prevalence of obesity (Bao et al. 1996). Many hormones play a role in fat regulation, among them cortisol, estrogen, androgen, and insulin, but hyperinsulinemia makes weight management particularly difficult.
Hyperglycemia is also involved in obesity. If the body takes in more carbohydrates than needed (glycogen stores are filled and energy requirements are satisfied), the leftovers are broken down (by the liver) to smaller fat molecules. The fat then travels to fatty tissues of the body where it takes up residency. Unlike the liver (which has limited glycogen capacity), fat cells can store unlimited quantities of fat (Whitney 1998). Researchers (addressing the conversion of glucose to fat) make the challenge that one has to be "prepared to play the game" if excessive amounts of carbohydrates are consumed (Hamilton et al. 1988).
Although obesity often parallels Type II diabetes (about 90% of newly diagnosed Type II diabetic patients are overweight), many obese patients do not display insulin resistance, and about 50% of hyperinsulinemic patients (those not yet diagnosed with diabetes) are of normal weight (Bogardus et al. 1985; Zavaroni et al. 1994).
BMI appears to be a valuable tool in assessing the gravity of obesity as a contributor to Type II diabetes. BMI may be calculated as follows:
Men: BMI >35 = 42-fold increase in diabetes
- Determine body weight in pounds and convert to kilograms (1 kg = 2.2 pounds).
- Determine height and convert to inches.
- Convert height in inches to meters. Divide height in inches by 39.37 (1 meter = 39.37 inches).
- Square height in meters by multiplying it by itself.
- Divide weight in kilograms by height in meters squared.
As problematic as a few extra pounds are in Type II diabetes, a weight loss can be just as significant. When Type II diabetic patients lost from 1.5-14% of their body weight, all diabetic parameters improved, that is, fasting blood glucose, hemoglobin A1c, plasma insulin, triglycerides, and HDL cholesterol. Those who lost 15% of their body weight were able to discontinue oral diabetic therapy. According to Priscilla Hollander, M.D., consuming 100 extra calories a day can result in a weight gain of approximately 12 pounds over 1 year; the consequence of consuming 200 extra calories a day reflects a 24-pound annual gain.
- BMI of 25 = 5-fold increase in diabetes
- BMI of 30 = 28-fold increase in diabetes
- BMI >35 = 93-fold increase in diabetes
Certain factors remain constant: a weight loss increases insulin sensitivity and deters the onset and progression of diabetes. Also, when blood insulin levels are reduced, the patient experiences an almost automatic weight loss. If the reader needs help with weight management, please consult the Obesity protocol for direction on suppressing excess insulin levels.
Simple and Complex Carbohydrates: Their Digestion and Absorption
Carbohydrates are probably the largest group of foodstuffs most individuals consume with regularity. It is estimated that 60-90% of the average American diet is composed of carbohydrates, ranging from simple sugars and fast foods to grains and starchy vegetables, such as potatoes, corn, and beans.
The least complex of all carbohydrates are the simple sugars (monosaccharides), which require virtually no digestion to metabolize. This means that after consumption they swiftly flood the bloodstream. If these food factors are eaten, it must be with extreme caution to avoid crowding the bloodstream with unnecessary burdens of glucose and insulin (Whiting 1989).
Glucose, a monosaccharide also known as dextrose, is the only sugar that can be utilized by the body. All other forms of starches and sugars must eventually be broken down and converted to glucose. Fructose or levulose (also a monosaccharide) is found in fruits and honey. The concept that fructose, in a concentrated form, is a better choice for the diabetic is erroneous; the release of fructose into the system takes only slightly longer than glucose. Fiber and attending enzymes in fruits assist in metabolizing the sugar, making naturally occurring fructose far less problematic than isolated concentrations. Unfortunately, fruits are not all equally safe for individuals with unstable blood glucose levels. Please consult the Glycemic Index (in this protocol) to read about fruits that are less likely to prompt a rise in blood sugar and an insulin rush.
The more complex sugars in the soluble group are made of double bonds (disaccharides) that are broken down by specialized enzymes within the body. Sucrose, common table sugar (a disaccharide), is one of the sweetest and perhaps the most tempting of all sugars. In order for sucrose to be absorbed, it must be broken down into two simple sugars, such as fructose and glucose. Lactose, also known as milk sugar, is the least sweet of sugars from the disaccharide group because it is less soluble.
The starch group of foods is regarded as insoluble. Starches are classified as insoluble because of the complex process required in breaking down complex starches into disaccharides and eventually to basic sugars or monosaccharides. Of all the carbohydrate groups, polysaccharides (complex carbohydrates) are probably the most beneficial to human metabolism. Types of polysaccharides (often extremely complex with long chains of glucose molecules) are cellulose (the primary constituent of plant cell walls), hemicellulose (the main constituent of cereal fibers), pectin (found in vegetables and fruits), and gums and mucilages (plant secretions). Examples of food sources include wheat, oat bran, and stalks and leaves of vegetables, seeds, and fruits. Raw, unrefined, or unprocessed carbohydrates are surrounded with other valuable food factors, such as protein, fats, vitamins, and minerals.
The time required to break down a complex carbohydrate minimizes the risk of overloading the body with a blast of sugar and a sudden release of insulin from the pancreas. A complex carbohydrate may, in fact, take hours to convert to glucose, rather than the few minutes required for processing a simple sugar.
Note: While complex carbohydrates usually serve diabetic individuals far better than simple sugars, some individuals find carbohydrates (in general) problematic. This likely occurs because of food allergies or exaggerated consumption of carbohydrates in relationship to other macronutrients (fats and protein). Consult the following section to learn the percentage of carbohydrates, proteins, and fats deemed most desirable in a diet to control blood glucose levels and symptoms of Syndrome X.
The Biochemical Nature of Macronutrients (Carbohydrates, Fats, and Protein)
Foods, that is, macronutrients, deliver powerful messages. According to Barry Sears, Ph.D., "Once food is broken down into its basic components (glucose, amino acids, and fatty acids) and sent into the bloodstream, it has a more powerful impact on your body and your health than any drug your doctor could ever prescribe."
The principal function of carbohydrates is to serve as a major source of energy for the body. If insufficient carbohydrates are available, the body will convert protein to glucose in order to supply energy (gluconeogenesis). The energy needs of the body take precedence over all other requirements (Krause et al. 1984). But, if consumed in excess, carbohydrates overwork the pancreas and are an invitation to obesity, diabetes, hypertension, hyperlipidemia, and some types of arrhythmias.
Proteins are the main structural components of cells and the enzymes that keep the cells running. Even our immune systems are essentially composed of protein (Sears 1995). However, proteins, when consumed in excess, create demands for vitamin B6 and calcium, stress the kidneys, and promote a weight gain. There are, however, several opinions regarding the influence protein has on insulin levels:
Poorly selected fats produce a harvest of undesirable (even destructive) hormone-like substances such as PGE2, a prostaglandin produced from arachidonic acid. It appears, however, that fats (saturated or unsaturated) neither increase nor decrease insulin levels. It is only when fats replace carbohydrates that insulin levels drop and the clusters of symptoms associated with Syndrome X become less apparent (Reaven 2000).
- According to various researchers, protein blunts a glucose rise and insulin response in normal glucose-tolerant individuals (Wang et al. 1991; Garg et al. 1994).
- Proteins primarily stimulate glucagon (a hormone that releases stored carbohydrates in the form of glucose from the liver); if too much protein is taken in at a meal, insulin levels will increase (Sears 1995).
- Dr. Gerald Reaven (head of endocrinology, gerontology, and metabolism at Stanford University) challenges: "Why trade one insulin-raising nutrient for another? It is far safer, and just as nutritious, to decrease carbohydrates and maintain protein at a reasonable level, while increasing your intake of the 'good' unsaturated fats" (Reaven et al. 2000).
- According to information in the American Journal of Clinical Nutrition, protein induces an increase in insulin concentrations when ingested in combination with carbohydrate. A mixture of wheat protein hydrolysate, free leucine, phenylalanine, and carbohydrate can be applied as a nutritional supplement to strongly elevate insulin concentrations (van Loon 2000).
While opinions differ on the amounts of macronutrients one can safely ingest at a meal, it is safe to say that carbohydrate begets insulin. In other words, the more carbohydrate consumed, the more insulin is secreted. The epidemic proportions of diabetes indicate many Americans are asking their body to run on fuel not recommended. Illustrative of the dietary transgressions our society has committed, in the early 1800s the per capita consumption of sugar (sucrose) was about 12 pounds a year. Today in the United States, the per capita consumption of sugar is more than 150 pounds a year. For every person who consumes only 5 pounds of sugar, there is another who eats 295 pounds annually (Challem et al. 2000).
According to Dr. Reaven, drawing 45% of calories from carbohydrate, 40% from "good" fats, and 15% from protein benefits individuals with Syndrome X. Nutritionists, reviewing the concept of macronutrient fractions, stress the importance of selecting healthy foods to supply requirements; eating ad libitum from unwise food choices (but within acceptable percentages) could still render the diet unhealthy from many perspectives.
The standard diabetic diet, currently recommended by most physicians, is very high in carbohydrates, about 65% of calories supplied by starches. This diet increases blood sugar, stimulates insulin production, and reduces the sensitivity of the insulin receptor. Steven Whiting, Ph.D., says that chronic adherence to a high carbohydrate diet ensures that the diabetic individual will be a patient for life, never recovering but slowly worsening in a downward spiral of ever-increasing side effects.
The current dietary trend away from fats and toward carbohydrates can be a fatal departure for an individual with Syndrome X and Type II diabetes. We have been led to believe that fats do little more than make us fat. A partial list of functions assigned to dietary fat discredits this logic:
According to data in the American Journal of Clinical Nutrition, trans fatty acids (often appearing in cookies, cakes, and processed foods) dramatically increase a woman's risk of developing diabetes. A trans fat (a fatty acid that the body is not able to successfully metabolize) results when a cis fat is exposed to hydrogenation, overheating, or refining.
- Fats slow the secretion of hydrochloric acid, prolonging the digestive process. Fats, therefore, provide more sustained satisfaction after meals and the desire to eat is delayed.
- Fats regulate the production of prostaglandins (hormone-like messengers).
- Fats serve as carriers for the fat-soluble vitamins such as vitamins A, D, E, and K. By aiding vitamin D absorption, fats keep calcium readily available to bones and teeth.
- Fats (omega-3 fatty acids) increase insulin sensitivity.
- Fats are mood enhancers, reducing levels of antagonism, rage, and despair. (Negative emotions transcend to impaired physical responses.)
Researchers (in the preceding study) followed the medical and dietary histories of 84,204 nondiabetic women over 14 years. From this group, 2507 cases of Type II diabetes were documented. Statistics showed that intake of total fat, saturated fat, and monounsaturated fat (as found in nuts, seeds and avocados), did not influence diabetic risk. However, a 2% increase in calories from trans fatty acids raised the risk by 39%, and a 5% increase in calories from polyunsaturated fat reduced the risk by 37%. It is speculated that substituting foods rich in trans fats with polyunsaturated fats could reduce the risk of Type II diabetes by nearly 40% (Salmeron et al. 2001).
Dietary choices of fats, generally regarded as good, may be obtained from olive oil (cold pressed, extra-virgin), almond oil and almond butter, seeds (pumpkin, sesame, and sunflower), avocados, and nuts (particularly walnuts, almonds, and macadamias). Other food choices rich in desirable fatty acids are delineated in the section entitled Essential Fatty Acids in the Therapeutic Section of this protocol.
Continued . . .
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