From hard experience, I have learned to ask my patients with diabetes whether their weight is up, down, or stable and, just as importantly, why they think this is happening. It’s always best to listen first.
We hear so much about weight being an issue for people with Type 2 diabetes, but maintaining a healthy weight can also be a struggle for people with Type 1 diabetes. Weight is such a sensitive topic, whether one has diabetes or not, and frustration over society’s inability to distinguish between Type 1 diabetes and Type 2 diabetes can make it even more difficult to discuss.
A recent study found that nearly ⅓ of the world’s population is overweight, so it should come as no surprise that some people with Type 1 diabetes might have trouble maintaining a healthy weight. However, people with Type 1 diabetes also have an added issue in that they depend on insulin, which is an anabolic hormone associated with weight gain; the tighter the glucose control from insulin therapy, the greater the possibility of weight gain.
The researchers who designed the Diabetes Control and Complications Trial (DCCT), the largest Type 1 diabetes study, hypothesized that insulin could be intensified without weight gain. The data from the DCCT found this not to be true. Patients who were intensively treated with insulin via pump or multiple injections experienced a 10-pound weight gain, on average, over those less stringently treated.
Researchers are trying hard to find alternatives to stand-alone insulin therapy that can deliver tight blood glucose control without weight gain. For example, they have focused on finding a way to utilize amylin, a hormone that is co-secreted with insulin, to reduce the required amounts of insulin needed before meals. Amylin, marketed as Symlin, is available for usage among Type 1 patients. Adoption of Symlin has been slow because it is given as an injection before each meal, in addition to each mealtime insulin dosage, and people are reluctant to add more three needle-pricks to their daily regimens. Another reason for Symlin’s slow adoption is that adding it to the insulin therapy mix means premeal insulin dosages must be adjusted to avoid hypoglycemia.
As with almost every aspect of diabetes care, a doctor’s attitude can either be a help or a hindrance when it comes to discussing weight issues. So many physicians, myself included, have been guilty of preconceived notions when it comes to overweight patients. Early in my career, if I saw a new patient who was overweight I automatically thought he or she needed motivation to diet. It never dawned on me that this patient might have already lost more than 50 pounds and was so proud of his or her success. Now I’ve learned to ask patients how they think their weight might be trending, and what they feel about their weight. I get much more information about this simple question than I would from looking at a chart, and certainly much more than I would from making an assumption.
Over the years, I have seen many folks who struggle with weight gain especially as they intensify their diabetes control. Many more fear the weight gain that comes from increasing dosages of insulin. One of the most important things I have learned is that people do things when they are ready. No amount of nudging, begging, pleading, or providing rationale data on the value of good diet and regular exercise will work until something within us says it’s time.
Ultimately, the best way forward may be to do away with stand-alone insulin therapy. I, and my team, have a singular goal of insulin independence for people with Type 1 diabetes. As we look forward to new therapies and clinical trials that combine immune therapy with beta regeneration therapy, the day may soon come when insulin may be a therapy of the past. Until then, it’s imperative for all who work with people with diabetes, both Type 1 and Type 2, to remember that weight is a complex physiological and psychological issue.
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