If you're a woman with diabetes, have you ever cut back on your insulin — perhaps just a little — because you've discovered that you can lose a few pounds in a few days by doing so? And then, when you go back to using your normal amount of insulin, are you dismayed to discover that you gain the weight back — and perhaps more — in equally rapid fashion? Over time, have you come to blame the insulin for your weight gain problems, so you take less insulin than you should — even though you're blood glucose runs higher as a result?
Over 40 women with diabetes, many of whom admitted to having let this familiar thought process influence their diabetes program, came together at Joslin's second Women and Diabetes symposium recently. The day-long symposium attracted nearly 100 women with diabetes who heard talks on topics ranging from the interrelationship of diabetes, menopause, and heart disease, to a session on having a healthy pregnancy if you have diabetes. One of the most popular sessions, however, was entitled "Living on the Edge." Presented by Joslin dietitian Karen Chalmers, M.S., R.D., C.D.E., who is the Director of Nutrition Services at Joslin, the session examined the balancing act women with diabetes encounter as they try to keep blood glucose in a safe range — and their weight down too.
"Most of the women at the session on insulin and weight gain were between 20 and 55 years old or so," notes Chalmers in an interview after the symposium. "Some were on intensive insulin therapy, but others were doing insulin manipulation to lose weight. This is a fairly common kind of problem in women with diabetes. Weight loss is a big challenge — nearly an obsession — with many women in this day and age. Our society is so hung up on being thin, and these women begin to feel that taking the right amount of insulin is causing them to gain weight, so they start cutting back, letting their blood glucose run high to stay thin."
The baby boomer generation is the first generation to be raised by mothers who were highly weight conscious, Chalmers believes. "Baby boomers have been called the children of the Weight Watchers generation," says Chalmers. "As a result, we have more of a dieter's mentality.
"When I asked the group at the seminar 'How many people have ever been on a diet?' every hand went up. 'Five diets?' Still every hand went up. About half the people in the seminar had been on 10 diets or more. I had a woman in my office recently who had spent over $10,000 on diets in the past seven years, and she's now the heaviest she's ever been in her life."
People attending the seminar were comfortable enough in the hour-long session to admit in front of others that they manipulate their insulin dosages to lose weight. But as Chalmers explained to them, it's not their insulin alone that is causing them to gain weight or preventing them from losing weight. And while taking less than the correct amount of insulin will lead to rapid weight loss, the weight lost will be mostly water and muscle being broken down, and not all fat. "And losing weight that quickly is unhealthy — not to mention the fact that keeping your blood glucose high makes you increasingly prone to long-term diabetes complications," she says.
But how do so many women come to believe that insulin is a root cause of their weight loss battle?
"When you don't take the right amount of insulin and your blood glucose run high, you can become dehydrated — which makes you think you've lost weight, but you've only lost water," Chalmers says. "Then, when you start taking your insulin in the appropriate amounts again, you start over-retaining fluids initially to make up for your dehydration, which makes you think you've rapidly gained a lot of weight. You associate it with taking insulin, but really what is happening is taking your insulin properly is just enabling your body to better use food and maintain a proper water balance.
"Or, maybe you are using less insulin and as a result your blood glucose will run high. High blood glucose can make you feel more hungry because not all the food you are eating is able to get into the cells as energy to nourish the cells. Then, when you've lost the weight you wanted to lose, you start taking the right amount of insulin again — and continue to eat the same amount of food. Only this time, because your body has enough insulin to process the food you're eating, you gain weight. Before, you were getting away with eating more food because your body couldn't use it properly. But once your blood glucose is in a more normal range, you're just using the food properly — and you gain weight."
Others who are using intensive insulin therapy may find they are gaining weight simply because they are over-treating low blood sugar reactions with too many calories, she says.
Some of the women on intensive therapy noted that the results of the DCCT showed that people on intensive therapy are prone to modest weight gain. "So they ask me, 'How do you expect me to lose weight when I'm on intensive insulin therapy? Doesn't insulin prompt you to cause your body to store weight as fat?' But that isn't what's happening at all. It's these other metabolic processes that are causing the weight loss, and the weight gain."
Women are more prone to weight gain — whether they have diabetes or not — for a variety of biological and lifestyle reasons. For example, women store fat more easily than men because female hormones tend to promote the formation of fat. Before puberty, boys and girls have about the same amount of body fat. Then after puberty (by around age 20), girls have 22 percent body fat, and active boys only have about 10 percent.
"In a nutshell, male hormones keep muscle mass high and fat levels low. Female hormones do just the opposite," says Chalmers.
The specific way men and women gain weight is different too. Women deposit fat from the bottom up — they gain weight in the thighs and buttocks first, then the stomach, and then finally on the upper body, arms, etc. Men gain weight first in the stomach — "the classic big beer belly." Whatever fat is gained first is the last to be shed — which is why it is so hard for women to lose weight on their thighs and rear end, and why weight loss seems to happen first in the face, neck and upper body.
There are a host of lifestyle reasons that lead to weight gain, too. Skipping meals actually causes your body to gain weight over the long haul, because when you skip meals, your body slows down its metabolism and becomes very efficient at conserving calories (instead of burning calories). "Your body does this to protect you, because your body doesn't know when you'll feed it again — it stores more calories as fat so you'll have reserves on hand for the next time you skip a meal.
"So if you eat little or nothing during the day and only eat at night, you're promoting higher weight — even if you aren't eating more total calories than you might have eaten if you ate three square meals a day — because your body is going to conserve more of those calories as fat.
The same thing happens to those who go on super low calorie diets. "If you are on too low a calorie amount, your metabolism is going to slow down and your body will adapt to being starved. So, super low calorie diets do not work long-term," she says.
The key to weight loss is not fooling with your insulin, or skipping meals or following the fad low-calorie diet of the week, says Chalmers.
The best way to lose weight is by keeping your metabolism sped up by spreading calories over the day, regular physical activity, and not skipping meals or following a diet too low in calories. If you are on a 1500 calorie a day diet, be sure you spread those calories over three meals and one to two snacks throughout the day. By doing that, fewer of the calories will be stored as fat than if you ate all the calories at one time. This will help keep your metabolism steady.
Chalmers also encourages people to move beyond the diet mentality and to learn more about the "set-point theory." "If you ask most people, they'll tell you that no matter how many diets they go on, their weight tends to go back to a certain weight — their 'set-point' — within a few weeks or months. Our set point tends to rise with age."
"I tell people to focus on the quality, not just the quantity, of food they eat when they are trying to lose weight or reset their set point," says Chalmers. "If you can change the quality, you most likely will lower the set point. So once you lower the set point, you can eat a normal low-fat meal and maintain the set point weight."
You have to be patient, she points out. "We've got to help people — especially women — get off this diet merry-go-round. Stop looking for the perfect diet. There isn't one. Why are there so many diets out there? Because none of them work. If one did, everyone would use it.
"There are people — many of us — who define food as good or bad. Their whole day revolves around food. They take their failure to lose weight as a personal failure. They lose a lot of their self-esteem, when the real truth is that diets just don't work unless they are individualized and relevant to one's lifestyle and food preferences.
"People with diabetes may let their sugars run high to lose weight," Chalmers says. "Imagine. You're risking your long-term health to lose weight."
There are programs to help people lose weight sensibly. Joslin's Fit and Healthy Program, for example, is a 14-week program that offers people with diabetes the opportunity to learn new patterns of eating and activity that will enable them to take weight off and keep it off.
For those whose problem isn't just weight, but an obsession with food, thinness, and losing weight, there are also people and programs who can help. The test will help you determine whether you may be too concerned about food and your weight and need some additional help because you have an eating disorder.
Certain antidepressant medications have been known to help patients with eating disorders begin to put food and their weight in perspective.
"Don't let food, and the desire to be thin, run your life," notes Chalmers. "We have to stop feeling guilty and punishing ourselves around food."
For many, food addiction is a self-diagnosable disease. See how many of these questions you answer "Yes."
If your answers to these questions concern you, you may need additional help. Discuss your answers to this quiz with your physician or your registered dietitian.
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Page last updated: June 30, 2015