War on Obesity & Diabetes

Diabetes prevention and conquering can be achieved by most people with the right support. The epidemic of obesity (complex pathophysiology in itself) and the resulting metabolic derangements known as Metabolic Syndrome[1] leading to diabetes, high blood pressure (hypertension), and hyperlipidemia (bad cholesterol, etc) are mostly due to vast complext factors influencing genetics and confounded by poor lifestyle habits that many humans have adopted in “recent” years. To defeat diabetes, one must fully understand the disease process and how all aspects of lifestyle affect that process in addition to the medications or surgery recommended by your physician.

You must know the literal definition of diabetes mellitus initially and then hear a medical perspective on it. Diabetes mellitus: “a disorder of carbohydrate metabolism, usually occurring in genetically predisposed individuals, characterized by inadequate production or utilization of insulin and resulting in excessive amounts of glucose in the blood and urine, excessive thirst, weight loss, and in some cases progressive destruction of small blood vessels leading to such complications as infections and gangrene of the limbs or blindness.” In all fairness to the definition, don’t forget about the resulting heart disease, brain (cerebrovascular) disease, kidney disease, and gastrointestinal diseases that result from the damage to blood vessels caused by the inflammation, “sticky” sugars and “fats” in the blood (not literally). Next definition, specifically for type 2 diabetes: “Form of diabetes mellitus characterized by diminished tissue sensitivity to insulin and sometimes by impaired beta cell function, exacerbated by obesity and often treatable by diet and exercise.”

Most people understand that their “sugar is high.” But do most people know why their sugar is high and why their doctors tell them to “eat better and exercise?” If people really understood and had a mental picture in their mind, I would bet that a much higher percentage would live the “DocsWhoLift” recommended lifestyle and succeed in their quest.

Fat, Protein, carbohydrates: digestion
First we must understand the basics of the food we are putting into our bodies.  Food is made up of three types of macronutrients: Protein, Fat, and Carbohydrates. Those are then broken into different types or categories depending on structure, function, or utilization when eaten. Check out our general dietary recommendations here. For understanding how diabetes and blood sugar works, we’ll focus on carbohydrates but overall energy balance is the critical component and then overall quality (plants, mediterranean pattern, etc).

Carbohydrate absorption: Glycemic index and Glycemic load
Starches (long chains of sugars attached together) and sugars, but not fiber, get digested (broken down) into the single glucose (simplest sugar) molecules in the gut. Once digested, the single glucoses can easily cross the gut wall and go into the blood stream. That is where “blood sugar” mixing occurs. Carbohydrates that have a “high glycemic index” break down very quickly and cause a rapid or sharp rise in the blood sugar. Carbohydrates with a “high glycemic load” are a source of calories/energy and cause an overall large rise in blood sugar, although maybe not as quickly if fiber or other macronutrients are included. Fiber is a form of carbohydrate that is not digested in humans and does not cause a rise in blood sugar, in fact it lowers glycemic index as stated above. Examples of high glycemic load/index starches include rice, potatoes, bread, and regular pasta while vegetables are a natural source of carbohydrates and are made up mostly of fiber, have low glycemic loads, and generally have negligible glycemic indices.

Carbohydrate utilization and storage: pancreas→insulin→muscle/fat uptake

The next concept to visualize is how the pancreas responds to the rise in blood sugar, by secreting insulin in an effort to normalize blood sugar levels to under 100 (the approximate level where your blood gets sticky) while initiating glucose uptake and subsequent utilization/storage by muscle/fat cells. Insulin works like a key by unlocking the garage doors of muscle and fat cells and then turning on the ignition switches of little sugar trucks called GLUT 4 transporters which are stored inside the cells. When turned on, these little trucks move to the

“Glut-4 Sugar Truck”he

cell surface, load up with glucose, and transport the loads into the cell to be stored or metabolized (used for energy). Some medications and supplements can also help this process (like mechanics), and exercise directly turns on the sugar trucks in muscle cells specifically. That is a very important point to remember.

Pathophysiology
Now that a good visualization of normal carbohydrate digestion/absorption, pancreatic function, and glucose uptake is accomplished, it is crucial to conceptualize the dysfunctional root of the Metabolic Syndrome: Diabetes (insulin resistance/glucose intolerance), Abdominal Obesity, Hypertension, and Dyslipidemia which leads to the inflammatory destruction of blood vessels causing the health problems already mentioned.

Vicious cycle
There is a vicious cycle which many people, especially westernized humans, have fallen victim to. This vicious cycle incorporates the current obvious problems of poor dietary habits, sedentary activity, resultant obesity (see this graphic from The Obesity Society on the vast complexities of influence), consequential metabolic/inflammatory abnormalities, and the psychiatric detriments which result from, and again leading to, the poor lifestyle choices which these people make; worsening the condition. It is hard to say where to jump into the vicious cycle when learning about its parts, so we’ll start with the physiologic culprit: the beer belly.

Visceral Fat and Adipokines

Visceral Obesity

The key is learning why it is so bad to have excess body fat, and most importantly a “beer belly.”  Rather than relying on the amount of fat, we stage the severity of obesity by the risk of where fat is stored and the complications resulting from that dysfuntional fat. Belly fat is due to the accumulation of visceral fat in the abdomen which surrounds the organs. Genetics plays an important role here, as you might remember the “pear vs. apple shaped bodies” analogy. It turns out that the belly fat, which gets a bad rap cosmetically, is really not too nice to your insides either. Visceral fat is very metabolically active and releases many hormones (some actually good like adiponectin) and inflammatory factors which are like weapons of “fat mass destruction” and cause many devastating problems[2] including insulin resistance/glucose intolerance, high blood pressure, lipid abnormalities, and blood vessel destruction. Visceral obesity is also an independent risk factor of mortality[3] (death)[4]. The diabetes is a direct result of the insulin resistance/glucose intolerance component.

Receptor dysfunction
The “bad” hormones (like resistin) actually disrupt the ability of the insulin “keys” to work on their cellular receptors (like broken garage door openers).

Glut 4 dysfunction (broken sugar trucks)

The “bad” hormones (particularly retinol-binding protein 4) also go above and beyond by directly disabling the little sugar trucks like jamming

Glut-4 Hijacker

something into the ignitions. As you can hopefully see, this combination can be lethal because if the sugar can’t get in, it just stays in the blood causing the blood to be more like syrup.

Inflammation, HTN, dyslipidemia etc
In addition to the “bad” hormones, visceral fat secretes other harmful cytokines and inflammatory factors which cause direct inflammation and destruction of blood vessels. Other reactions to these weapons of “fat mass destruction” include dangerous elevations in blood pressure (hypertension is the silent killer), and hazardous (and dysfunctional) levels of cholesterol in the blood (high triglycerides, low good HDL, high bad LDL cholesterol)[5].

Weapons of “Fat Mass” Destruction

Excess Carbohydrate

Since the advent of agriculture over 10,000 yrs ago, humans have become more reliant on “empty” calories from grains, corn, etc because they are cheap sources of high quantity food stuff. This has exponentially worsened in recent years due to increased refinement of grains and other mass produce calorically dense starches, fast food and most other restaurants, and a lack of knowledge combined with reckless disregard for personal health and longevity. In regards to the interaction of carbohydrates and insulin resistance/glucose intolerance, we’ll look closer at the glycemic indices and loads of the carbohydrate sources which humans consume. Carbohydrates and sugars are not the sole root cause per se, as energy balance and dietary quality is influenced by many factors including types of fat sources, palatibility of food, etc.

Excess index

Starches like white bread, pasta, most cereals, potatoes, and white rice are basically made by jamming lots of grain-type plants together after being stripped of anything nutritious forming calorically dense “empty” foods. These highly refined sugars which are loosely linked together quickly break down into glucose when eaten and move into the intestines. That means that those, along with calorically dense drinks like sodas and juices, have high glycemic loads and indices causing a significant excess energy balance leading to weight gain and rise in blood sugar when consumed. Imagine how “sticky” one’s blood is if there is a large amount of sugar in it, not normalizing because of the dysfunctional cellular garage doors and sugar trucks! Not pretty.

Excess load

“Blood like syrup”

Now, for very active people, like highly competitive athletes who train intensely, there is often a need for higher caloric diets rich in starchy carbohydrates just to survive and continue training. Better choices for them would be whole grain breads and pastas, high fiber cereals, sweet potatoes, and brown or wild rice. Those choices have higher fiber content, less “empty” calories, but still have a high glycemic load essential to the athlete, but potentially dangerous to somebody trying to lose that gut and fight the insulin resistance/glucose intolerance. Hence the term, “glucose intolerant,” alluding to the fact that the insulin is not working and the cells have no use for the glucose sugars. So unless those sugar loads are consistently being used as fuel for muscles and brain activity, the sugar will still rise significantly in the blood and since the sugar trucks are not doing their job, the sugar just stays there causing all sorts of problems. On the other hand, a low fat or veggie-based diet can incorporate these foods with great benefits when the overall diet is high in quality and leads to weight loss.

Sedentary muscles
We all know that one of the major contributors to the obesity epidemic is the relatively sudden onset of human laziness, a much more sedentary lifestyle than our ancestors employed. It is no secret that more physical activity burns more fuel (calories) and exercise would prevent many of the detrimental health issues facing the human race today, ie. obesity, diabetes, etc.  But in addition to the obvious lack of exercise leading to the big bellies causing all of the problems, there are other direct mechanisms by which exercise, or a lack thereof, influences the process of insulin resistance/glucose intolerance.

Exercise increases insulin sensitivity

Carbohydrate utilization

When our muscles are not being used on a constant basis, there is no fire to add the fuel to. Just like an old locomotive, a constantly running engine uses fuel, but in our bodies if that glucose is not burned as fuel it gets stored as fat. If it gets stored as visceral fat, you now know the detrimental effects that it will have.

Glut 4 laziness (dead batteries in the sugar trucks)
A very important adverse effect of not using your muscles regularly is seen when looking at how the little GLUT 4 sugar trucks work even in the absence of the insulin keys to turn the ignitions. Exercising any muscle directly activates the GLUT 4s, causing them to transport glucose into the cells[6]. Without exercise, it is like the sugar trucks all have dead batteries and have another reason to not be doing their jobs, leaving all the sugar in the blood to harm our bodies.

How to fight and win the battle
#DocsWhoLift Cycle – Attempt to break all links of the vicious cycle.
Now the fun part: you can fight! You do not have to fall victim to the misery and early death that accompanies the Metabolic Syndrome. The goal is to break every little component of the Metabolic Syndrome Vicious Cycle and reverse the direction leading to a better feeling, better functioning, longer living, better looking, happier you.

Losing the gut and fighting the bad guys
As you can already see where this is going, what is the main thing that needs to be defeated? The evil abdominal fat, beer belly, gut, etc is an essential inciter of insulin resistance/glucose intolerance. You have to lose that fat and get rid of the bad hormones and inflammatory factors.

Negative caloric balance
The very simple initial idea is that you must create a negative caloric balance. More energy must be burned than is consumed in order to start using the abdominal fat for fuel. That is easier said than done, as the complex pathophyiology of obesity has been noted above. But with effort geared toward a dietary plan, exercise plan, behavioral plan and potentially medical or surgical assistance from your doctors, treating obesity is within your grasp!

Fiber
Fiber is that carbohydrate which is not digested by humans. There some important ways in which a diet high in fiber helps fight or prevent obesity and diabetes. High fiber consumption lowers glycemic index and helps with a feeling a satiety or fullness causing decreased eating.  Soluble fiber actually decreases bad cholesterol[7] and increases the “good” hormones, like adiponectin, released from the abdominal fat which actually improves blood lipid levels and glucose tolerance (including improvements in HbA1c)[8]. Finally, a high fiber to total carbohydrate ratio (vegetables are often 1:2 while pasta is like 1:25) will generally lead to a negative caloric balance and decrease the glycemic load by not even breaking down and crossing into the blood stream.

Quality of dietary fat
Unfortunately dietary fat intake has gotten a bad rap over the last 30 years with a big thanks to the old food guide pyramid. Please note the differences between the old pyramid, which we think was initiated by the cereal companies, and our pyramid in the Diet section of LeanerLiving. This is a shame because many fats are essential to human health and if consumed in the correct balance of types of fatty acids, actually improve health, aid fat loss, and fight the Metabolic Syndrome. Increased consumption of omega-3 polyunsaturated fats from sources like salmon have been shown to increase insulin sensitivity[9], mono-unsaturated fats from olive oil and almonds have repeatedly been studied as cardiovascular helpers, and even the old dreaded saturated fat has a role when consumed properly[10].  Nuts specifically have an abundance of evidence to show their benefit[11] in all who consume a variety including pistachios[12], walnuts, and all the others.

Decreased glycemic load
To use the Law of the Conservation of Energy for good instead of evil, it is imperative for those with glucose intolerance to just decrease the amount of glucose which enters the bloodstream. Eating carbohydrates with very low glycemic loads is an effortless way to accomplish this. But what sources of carbohydrates have the lowest glycemic load? Well, what did our ancestors eat before agriculture provided us with all the calorically dense starches? Vegetables!

Vegetables as source of dietary carbohydrate intake
Vegetables are the epitome of being opposite from “empty calories.” They are calorie for calorie far superior nutritionally to any other source of carbohydrate. Fruits, especially berries, are a close second. The fiber to carbohydrate ratio of vegetables ranges from very good (app. 1:4) to plain outstanding (1:2 for broccoli).  Using vegetables, and to a lesser degree berries, as the primary sources of carbohydrate consumption will cause a negative caloric balance, provide tons of nutrients and antioxidants, and provide the soluble fiber which will help defeat the attacks from the enemy visceral fat while preventing or treating diabetes[13]. I dare anyone to get fat by eating too many vegetables.

Exercise
Now let’s discuss how to break the vicious cycle component of sedentary flaccid musculature. Your doctor tells you that exercise is important, but you just never seem to be able to put it as a top priority, right? Well maybe knowing why and how exercise directly improves your chances of beating diabetes will motivate you. Check out our Exercise section for more specific information.

Glut 4 activation (jump starting the dead batteries)

Jump start your sugar trucks!

The problem with insulin resistance and glucose intolerance is that our little muscular sugar trucks aren’t working anymore. Well guess what, exercising a muscle directly activates those little sugar trucks like jump starting their battery or hot-wiring them. If one muscle is exercised in a resistance training type meth.od for one 45 minute session, all those sugar trucks of that muscle will work for approximately 20 hours depending on the amount and intensity of the exercise. Muscular activity also directly decreases circulating levels of the “weapon of fat mass destruction” retinol-binding protein 4 meaning there is less of an attack on the sugar truck in the first place. That is why we suggest doing at least two days per week of resistance training for each major muscle group (pushing, pulling, legs) to incorporate all the possible sugar trucks and keep a steady state glucose transport at all times. In addition to resistance training, it should be understood that some form of exercise every day is vital to win the war against diabetes[14].

Caloric expenditure leading to decreased visceral fat
Participating in some form of exercise every day on a consistent basis, causes the muscle cells at work to utilize glucose and fat for fuel. Constantly running our muscular engines like an old locomotive will keep the blood glucose at bay and slowly consume that bad visceral fat for energy. Intense exercise also causes hormonal changes which help to break down the fat stored in the body in order for it to be used as fuel even when not exercising.  Combined with a Leaner Living diet, the belly fat will melt away.

Muscle growth leading to more sugar trucks and higher metabolism
Keeping with the same analogy of muscles acting as engines, imagine having bigger engines to burn more fuel. Proper resistance training at least two days per week for each major muscle group will lead to muscle cell growth (muscular hypertrophy). So in addition to turning on more sugar trucks, there will simply be more of them and there will be more activity in the sugar/fat metabolism factories leading to fat loss which will decrease the negative forces from the belly fat. Adding in some good resistance training with other cardiovascular / healthful and calorie burning activities is a great and essential weapon to defeat diabetes.

Medications and supplements
Many medications which are prescribed by doctors on a personal basis can help modify the deleterious efforts of the visceral abdominal fat. Discuss with your physician about all the options and what might be right for your situation. Do not depend on prescribed diabetic drugs to fight the battle, they are only allies in the war and will not win the war for you. There are also many other supplements being researched and developed in an attempt to aid in the war against diabetes. Be careful what you consume, and always talk to your physician before trying anything new. Just remember that these medications and supplements will not change your lifestyle, you must make that decision yourself.

The Law of Conservation of Energy: “Energy cannot be created nor destroyed; it can only be changed from one form to another.” In simple terms, especially as a diabetic with glucose intolerance, the blood sugar has to come from somewhere. It is either going to come from the liver where it is stored as glycogen (the medication metformin or supplement Glycosolve should help with that part) or it comes from what you put into your mouth.

Conclusion
The war will be won when you combine all the forces and components of the DocsWhoLift Cycle and put your health as a top priority. You must understand and have a picture in your mind of what is really going on in your body. Then you will have the incentive to attack and break apart the metabolic syndrome’s vicious cycle. Visualize how the enemy is the fat in your belly, sending out evil troops to break down your sugar trucks and render inoperative the metabolic factories in your cells. Know what happens when you eat empty carbohydrates and bad fats (which is similar to selling weapons to the enemy) compared to eating lean meats, healthful fats (nuts/seeds, olives, fish, etc), and lots of fibrous vegetables/legumes/fruit (which is like keeping the best weapons on your side). Imagine what your muscles are doing when you don’t use them very often, not being productive parts of your body’s internal civilization. Turn that vicious cycle into a DocsWhoLift cycle and fight the little battles to win the war. Eat fewer calories but more importantly eat quality calories. Never drink sugary beverages like soda or juice,[15] and replace with water or diet beverages[16]. Vegetables should be the primary source of carbohydrates followed by legumes and fruit, all with high fiber to total carbohydrate ratios and filled with the nutritious value our bodies need for optimal health. Lean sources of quality protein like poultry, eggs, fish, beef, and dairy should account for at least a portion of every meal and special care should be made to balance fat intake focusing on sources like fish, nuts, and olive oil. The so-called “fad diets” that have positive evidence behind them include plant-based diets, “Mediterranean[17],” “Paleo[18],” and low-carb[19] like “Atkins.” We try to give our advice based upon the whole picture of evidence from all the studies regarding those diets and other smaller components in order for our patients to have all the dietary tools. Treats should be treated as such; no pun intended. If dessert type foods are eaten every day, then they are not treats but just a miserable part of your regular diet contributing to the malevolent forces on the other side. Eaten once in a while, they fit the definition of “treat” and can be a fun and safe part of life. Take your medication as prescribed and use safe and effective supplements with research to back them up, but do not rely solely on those to fight the war for you. Remember the Law of Conservation of Energy and use that concept to help keep your blood sugars at bay. Finally, you must find a way to exercise every day to decrease the bad belly fat and help out the sugar trucks and sugar/fat burning factories. Failure is not an option for a long and healthy life so take this briefing seriously, prepare for battle, and win the war against diabetes. It is your assignment, should you choose to accept it.