If you have type 2 diabetes, it should come as no surprise that lifestyle has a major impact on your diabetes—especially your blood-sugar control—and that lifestyle changes can have a beneficial effect.
As explained in Chapter 1, type 2 diabetes represents the end of a long and somewhat complicated road on which insulin resistance, or decreased insulin sensitivity, and the inability to make enough insulin contribute to rising blood sugars. At first, blood-sugar levels begin to rise slightly after meals because, in the setting of insulin resistance, the breakdown products of the meal are not normally stored in the muscle and liver. During this pre- 149
diabetic phase, there are no symptoms and fasting blood-sugar levels remain in the near-normal range. Prediabetes can sometimes be detected with a fasting blood-sugar test, but more often a stress test called a glucose-tolerance test is required. In most persons who are destined to develop diabetes, the next five to ten years are characterized by increasing insulin resistance and decreasing insulin secretion.
Type 2 diabetes is ultimately a problem of supply and demand. The body demands more insulin to do its work, and the pancreas over time fails to supply enough insulin. When diabetes finally develops, it is usually the result of too little insulin being secreted to do the job. Blood-sugar levels rise more dramatically, including the fasting blood-sugar level, and the complications associated with hyperglycemia begin to develop over time.
How does lifestyle play a role here? The most common cause of increasing insulin resistance is being overweight and having decreased physical activity levels. In addition, and as pointed out in Chapter 3, changing the lifestyle factors that lead to overweight and obesity can reverse, to a great extent, their damaging effects. The same benefits can be seen even after diabetes has developed. Therefore, changes in lifestyle that lead to increased activity levels and decreased weight can improve type 2 diabetes even after it is entrenched.
How is it possible to turn back type 2 diabetes after it has started? It is possible because the insulin resistance that has contributed to causing type 2 diabetes can be reversed by lifestyle changes. It is also possible because the exhausted pancreas— which gives out after many years of making large amounts of insulin to compensate for the effects of insulin resistance—can recover if it gets a breather. The insulin-secreting beta cells are fatigued, but they aren't dead, especially early in the course of type 2 diabetes. There are some diseases that are irreversible once they occur. When someone has a heart attack, for example, the affected part of the heart muscle remains dead ever after. With type 2 diabetes, however, there is a window of time when you can reverse the disease with lifestyle changes. The earlier those changes are implemented, the more likely that improvement will occur.
The first treatment strategy that is almost always applied in the 90 percent of people with type 2 diabetes who are overweight or obese is to implement a weight loss program characterized by both changes in diet and increased exercise or activity. These lifestyle changes can have near miraculous results with regard to blood-sugar levels—even before much weight is lost!
Within days of eating fewer calories, blood-sugar levels often plummet, making the use of medications unnecessary. This has been demonstrated in numerous studies. Why a decrease in calories, even before weight loss occurs, improves blood-sugar levels so dramatically is not entirely clear, but the most likely explanation is that there is an improvement in insulin secretion that occurs rather quickly with levels of insulin resistance falling more slowly.
Increased physical activity also can lower blood-sugar levels even before you have had substantial weight loss, because it makes your muscles more sensitive to insulin, which drives sugar from the blood into the muscles. Over time, increased physical activity will contribute to achieving and maintaining weight loss. The more prolonged changes in lifestyle that result in weight loss will also have the effect of decreasing insulin resistance with a further recovery of insulin secretion.
Many health-care practitioners and people with diabetes are skeptical about the value of diet changes in treating type 2 diabetes. That's because they know how hard it can be for people to continue their diets over the long term. However, we found that the diet and exercise programs used in the Diabetes Prevention Program could be maintained by most of the participants over several years. The same should be true for you.
Studies in recent years have clearly shown that weight loss— achieved in a number of different ways—can make type 2 diabetes much less severe and can even make it disappear. A dramatic example is what happens in enormously obese people—who are usually at least 100 pounds overweight—who undergo so-called bariatric or weight loss surgery. In these individuals, weight loss of 80 to 120 pounds often occurs in the first year after surgery, and almost 90 percent have reversal of their diabetes. At a minimum, such persons can stop most of their medications, and many of them are able to stop all diabetes medications and maintain normal blood sugars.
So if weight loss is effective and sustained, diabetes can be reversed. In most people who are not very overweight, bariatric surgery is not indicated because of its risks. For most people, the answer will not be surgery but a lifestyle approach such as the one used in the Diabetes Prevention Program and described in this book. Our early experience is that people with type 2 diabetes can successfully follow this program just as can people who are at risk for diabetes. We think it is possible that treating newly diagnosed type 2 diabetes with an effective lifestyle program will not only prove successful but may be even better than conventional treatment with medicines.
Why do we think that? It's because medicines can reduce blood sugar, which is important, but blood-sugar-lowering medicines do not have direct effects on the other major diseases that often travel with diabetes: high blood pressure, high cholesterol, heart disease, stroke, and related diseases. The lifestyle program described in this book, however, can reduce the risk of (and can even help treat) most, if not all, of these risk factors at the same time it is helping treat diabetes.
In fact, a lifestyle program similar to that used in the DPP and described in this book is now being tested in the large Look: AHEAD study, sponsored by the National Institutes of Health (NIH). The Look: AHEAD study is testing the theory that, in people who already have developed type 2 diabetes, effective lifestyle intervention will improve diabetes and other cardiovascular disease risk factors and, ultimately, reduce heart disease, compared with standard diabetes therapy. In the absence of the effective lifestyle intervention developed by the DPP, this study would not have been possible.
As with preventing diabetes in people with prediabetes, the successful treatment of diabetes once it has developed does not require unattainable changes in lifestyle. You don't have to lose an enormous amount of weight or become a marathon runner. Many studies have shown that a ten- to twenty-pound weight loss will be sufficient to reduce insulin resistance, increase insulin secretion, and lower blood-sugar levels.
These are the nutrition lifestyle priorities for achieving blood-glucose levels as close to normal as possible and a hemoglobin Alc level below 7 percent for people with type 2 diabetes:
• Lose at least five to ten pounds to start. Consider whether you can continue to lose a total of 7 to 10 percent of your initial body weight (as described in Chapter 8). Reducing your calorie intake to lose weight is the most powerful lifestyle change that you can make to lower your blood-sugar levels. The weight loss recommendations that we will discuss to prevent diabetes can also help to manage type 2 diabetes. If you are lean and do not have an extra five to ten pounds that you can afford to lose, then focus on these other suggestions. They will help control your blood-sugar levels by keeping your carbohydrate intake moderate at each meal and snack by minimizing liquid carbohydrates, distributing solid carbohydrates into three meals and two to three snacks, and incorporating more fiber.
• Reduce or eliminate sweetened or naturally sweetened beverages. These include regular soda, fruit punch, and natural fruit juices. Carbohydrates in liquid form are more rapidly absorbed than carbohydrates in a solid form (solids usually contain fiber that slows down the digestion of sugars) and can cause your blood sugar to rise to high levels. Instead of regular soda, try sugar-free diet soda, which has no calories. It is best to limit fruit juice to four ounces per day or to eat fresh fruit instead. Fresh fruit has fiber, is more filling than juice, and is more slowly digested and absorbed.
• Try several small meals at regularly timed intervals rather than infrequent large meals. It is better to space your meals and snacks throughout the day than to skip meals and eat one or two large meals. Your pancreas has to produce insulin every time you eat in proportion to the amount you eat at each sitting. If you eat large amounts of food containing large amounts of carbohydrate at a given meal, your pancreas has to strain to produce more insulin, and you will notice higher blood sugars afterward. On the other hand, if you distribute your calories into three meals and one to two snacks per day, your pancreas will have an easier time producing enough insulin to cover the smaller amounts of food and carbohydrate at each meal or snack.
• Include more fiber in your food choices. Fiber has several beneficial effects. It satisfies hunger, blunts the rise in blood sugar, and lowers cholesterol levels. Choose fresh fruits instead of juice, whole grain breads and cereals instead of refined grains, and increased amounts of fresh or frozen vegetables.
• Increase your activity level. Gradually work toward a goal of at least thirty minutes of activity (equivalent to a brisk walk) five to six times per week (discussed in the next chapter). This level of activity can often lower your blood-glucose levels by fifty or more points. When you exercise, you help the insulin that your pancreas produces to work more effectively.
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