Living With Diabetes

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Living With Diabetes. There is no cure for diabetes, but it can be managed. Balancing the food you eat with exercise and medicine (if prescribed) will help you control your weight and can keep your blood glucosethe main sugar found in the blood and the body's main source of energy

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Praise for the First Edition To Kill Diabetes Permanently Click Here ‘‘Boris Draznin is an accomplished scientist and clinician who provides a sound scientific basis for his unique approach to the prevention and treatment of diabetes. The emphasis is placed on obesity and lifestyle modifications. Importantly both sides of the energy balance equation—food intake and activity—are stressed. The Draznin Mile and Draznin Calorie are practical concepts that make his plan easier to follow. Dr. Draznin’s numerous patient experiences exemplify his points while offering a personal and comforting encounter for the reader. An important and parting note encourages those at risk for diabetes or with diabetes to choose physicians with the knowledge interest and time to deal with this important problem.’’ –Robert H. Eckel M.D. University of Colorado Health Sciences Center ‘‘The prevalence of diabetes and obesity has reached epidemic proportions in America leading to an enormous health problem. This new book by Boris Draznin will be of great help to anyone trying to deal with the problem of excess weight. It is highly readable medically correct and filled with useful practical advice. Dr. Draznin carefully explains the basic concepts of calorie balance and weight control and then goes on to describe a lifestyle program that anyone can adapt to their own needs. Using his approach people will be able to take charge

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of their attitudes and behaviors towards calories and exercise and thereby take control of their weight.’’ –Jerrold M. Olefsky M.D. University of California San Diego School of Medicine ‘‘In his book The Thinking Person’s Guide to Diabetes: The Draznin Plan Boris Draznin brings the same wit excellence and passion to the reader that he does in person. The concepts of the Draznin Calorie and the Draznin Mile bring lightness reality and possibility to the chore of day-to-day living with diabetes mellitus. Each reader will find his or her own path using his approach. I heartily recommend this book to all people with diabetes.’’ –Gerald Bernstein M.D. F.A.C.P. Past President American Diabetes Association ‘‘The Thinking Person’s Guide to Diabetes: The Draznin Plan is written by a world expert in diabetes and obesity but is readily accessible by the layman. It gives practical advice to overweight individuals but is definitely not a fad diet book because it is founded on evidence-based medicine. This excellent book offers a very balanced approach to diet and exercise—it’s proven to work.’’ –Derek LeRoith M.D. Ph.D. Chief of the Division of Endocrinology Diabetes and Bone Disease Mount Sinai School of Medicine

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Living with Diabetes To Kill Diabetes Permanently Click Here Dr. Draznin’s Plan for Better Health Boris Draznin MD PhD

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1 2015

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1 Oxford University Press Inc. publishes works that further Oxford University’s objective of excellence in research scholarship and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Copyright 2008 by Oxford University Press Inc. Published by Oxford University Press Inc. 198 Madison Avenue New York New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any

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means electronic mechanical photocopying recording or otherwise without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Draznin Boris. Living with diabetes : Dr. Draznin’s plan for better health / Boris Draznin. p. cm. Includes index. Revised ed. of: The thinking person’s guide to diabetes. 2003. ISBN 978-0-19-534166-9 1. Non-insulin-dependent diabetes—Popular works. 2. Weight loss— Popular works. I. Title. RC662.18.D73 2008 616.462 –dc 22 2007052458 9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

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v Preface to the Revised Edition Since the year 2003 when the first edition of this book was published the epidemic of obesity has continued unchecked by heightened public attention hundreds of articles in scientific and popular periodicals multitudes of broadcast news pieces about the dangers of obesity and an unstoppable proliferation of diet books and dietary advice for children and adults. Along with obesity the prevalence of diabetes has also continued to climb. According to one study from Canada the number of people with diabetes in Ontario in 2005 exceeded that predicted by scientists for the year 2030. Regretfully we are twenty-five years ahead of this sobering health prediction and we are losing the battle with obesity and diabetes. While we anxiously await the discovery of a magic pill that would either effectively and safely curb our appetites or prevent weight gain in some other way I offer the Draznin Plan as a healthy and successful way to prevent and treat diabetes in most people who make a commitment to follow it.

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vi In this revised edition of the book I will introduce a few new steps that will make it even easier for readers to adopt the Draznin Plan and with it a healthier lifestyle. All of the advice

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vii Preface to the Revised Edition given to my readers in the first edition still stands: Build an attainable and practical exercise program of three Draznin Miles per day and never buy or eat anything that contains more than 2.5 g of saturated fat or 6 g of sugar per serving. I sincerely hope this new edition will help more people with diabetes and prediabetes join the ranks of those who have already successfully embraced the Draznin Plan and a healthier longer life. B. D. Denver Colorado 2007

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viii Preface to the First Edition Not a week passes by without a story in the news media about the epidemic of obesity and type 2 diabetes in the United States. These stories appear regularly in major national news publications and on television. This epidemic is not limited to the U.S. borders Canada England and other industrialized nations are experiencing these same intractable health problems. This epidemic is real. It is frightening. It has colossal implications for the health of our population and for the healthcare system in general. Obesity and type 2 diabetes are silent killers responsible for the shortened life expectancy of many people. One of the most important complications of type 2 diabetes is the acceleration and progression of cardiovascular disease leading to heart attack and stroke. Needless to say these complications significantly and adversely affect both life span and quality of life. At the same time clinical trials have convincingly demonstrated that type 2 diabetes can be prevented. One study showed that modifications in eating habits and activity

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ix patterns effectively prevented diabetes in almost 60 of ‘‘prediabetic’’

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x Preface to the First Edition patients. We have also learned that weight reduction helps control blood pressure and cholesterol problems. The old adage about ‘‘an ounce of prevention’’ takes on new meaning when it is applied to weight problems and diabetes. Prevention of type 2 diabetes literally saves lives. Understanding the problem does not necessarily mean that a solution is at hand however. Losing weight and maintaining a new ‘‘reduced’’ appearance is far from being a trivial task. The sheer number of books offering a ‘‘simple and quick’’ weight-loss plan tells me and it is hoped you that the problem is much more complex than these books imply. Otherwise we would have solved the problem of obesity long ago. The truth is there is no single recipe for weight loss. Weight maintenance requires a long-term commitment to a different therapeutic lifestyle. Diabetes and obesity are two chronic conditions that cannot be cured or even controlled without the patient’s active involvement. This book is meant to offer help to those

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xi who are ready and willing to get involved. My plan for weight loss and better health which I’ve aptly named ‘‘the Draznin Plan’’ is based upon three principles: scientific facts an individualized approach and unwavering commitment to lifestyle changes. The lifestyle changes presented in this book will help you attain your goals—to improve or prevent type 2 diabetes and to maintain a healthy weight. However only the combination of the Draznin Plan with your own personal commitment to my recommendations will bear the desired fruit. In other words here I offer you a simple easy-to-maintain plan for getting and staying healthier—actually following the plan will be up to you. B. D. Denver Colorado 2003

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xii Contents One: At the Beginning 3 A Letter to My Reader 3 An Introductory Case 7 The Origin of the Draznin Plan 11 Two: Our Weight in Numbers 13 Ideal Body Weight and Body Mass Index 14 Obesity Rates Are Climbing 17 Why Are We Becoming More Obese 20 Obesity and Its Relationship with Diabetes 23 Three: The Law of Conservation of Energy 27 Energy Consumption and Expenditure 28 How Calories Are Absorbed or Not 31 How Calories Are Utilized or Not 33 Insulin Levels and Activity 34 Four: The Draznin Mile: A New Concept of Exercise 36 Understanding the Draznin Mile 38

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xiii Getting Started 41 Finding Alternative Forms of Exercise 43

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xiv Contents Five: Insulin Production and Storage of Energy and Regulation of Weight 46 Glucose in the Body 47 Turning Food into Energy 52 Case Study: Mr. G. 56 Commonsense Conclusions 58 Six: A Person Does Not Lose Weight by Diet Alone 59 The Importance of the Hypocaloric Diet 60 Understanding Dietary Composition 65 Diet Plus Exercise 69 Seven: A Tale of Two Brothers 72 Two Brothers Two Treatment Plans 74 Getting Individualized Care from Your Doctor 76 Two Patients One BMI 79

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xv Eight: Treatment of Obesity Easier Said than Done 82 Realistic Expectations 84 The Energy Value of Foods 89 81 Medications and Other Chemicals 92 Medicating Prediabetes 96 Nine: What Shall I Do When I Stop Losing Weight Despite My Best Efforts to Keep My Diet and Exercise 98 Keeping Goals Reasonable 99 Changes in Cognitive Function 102 Ten: The Draznin Calorie: A Better Way to Diet 104 A Calorie by Any Other Name... 105 Eleven: Practical Advice 111 Portion Size 111 Added Sugars 112

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Contents xi Glycemic Index 113 Dietary Fat 116 Alcohol 117 Eating Out 119 Vitamins and Supplements 120 Prescription and Over-the-Counter Medications 122 Cooking and Eating at Home 122 Grocery Shopping 123 Dairy Products 125 Meat 126 Soy 127 Snacks 127 Twelve: My Own Personal Struggle to Prevent Diabetes 131 A Growing Boy 132 Initiating Dietary Change 133 Finding the Right Exercise Program 134

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Thirteen: Case Studies and a Treatment Plan for Mr. K. 138 Ms. Elizabeth E. 138 Mr. Frederick D. 141 Case Study 1 145 Case Study 2 147 Case Study 3 148 Diet 151 Exercise 152 Lifestyle 154 Appendix A: Recommendations Based on Ten Draznin Rules of Life 157 Appendix B: Frequently Asked Questions 159 Resources 169 Index 171

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Living with Diabetes

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Chapter One At the Beginning To Kill Diabetes Permanently Click Here A Letter to My Reader When you took my book from the shelf in your favorite bookstore or library you may have wondered what is so special about my program. In what way is Dr. Draznin’s

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approach to weight loss and a healthier lifestyle better than dozens of others staring at you from the same bookshelf What is the secret of the Draznin Plan that allows his patients to defeat their obesity and type 2 diabetes—the most common form of diabetes Not only do I encourage you to ask these questions but also I hope you find convincing and reassuring answers in my book. I believe firmly that the more people understand about their weight problems and diabetes the greater will be their com- mitment to improving their health and the greater their chances for success. In most cases weight maintenance and prevention of type 2 diabetes which is frequently associated with I believe firmly that the more people understand about their weight problems and diabetes the greater will be their commitment to improving their health and the greater their chances for success. 3

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4 Living with Diabetes excess weight and insulin resistance—an inadequate action of insulin are in the hands of patients themselves and my role as a physician is simply to guide them through the often confusing obstacle course of energy intake the number of calories we consume and energy expenditure the number of calories we burn. Having treated thousands of patients with diabetes and obesity over more than three decades of academic medical practice I have developed a unique program: the Draznin Plan. It is built on a solid scientific foundation is easy to understand and follow and has proven successful by patients who made a true commitment to their lifestyle changes. The Draznin Plan is based on three principles—‘‘a threelegged stool’’ if you will. The first is the science of clinical medicine nowadays known as ‘‘evidence-based medicine.’’ The cardinal feature of contemporary Western medicine is its reliance on controlled clinical studies to identify which treatments work and which do not. Anecdotal success stories individual experiences with exotic therapies

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5 Living with Diabetes and the popularity of nontraditional medical practices cannot substitute for the rigor of clinical research and scientific statistical analysis. Only proven therapies should be accepted as standards of care. The field of weight maintenance is not an exception. Numerous clinical studies have repeatedly shown that any person on a low-calorie diet is going to lose weight. Interestingly however exercise without an accompanying diet failed to yield significant weight loss. Thus telling patients that they can lose weight simply by increasing their energy expenditure would be misleading. In contrast other studies have convincingly demonstrated that after an initial weight loss only those individuals who have incorporated exercise into their lifestyle have been able to maintain their reduced weight. The others regained their pounds. These studies are telling us that neither a low-

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At the Beginning 6 calorie diet without exercise nor exercise without a low- calorie diet is adequate for long-term success in weight maintenance. This is why the combination of the Draznin Mile and the Draznin Calorie which you’ll learn about a little later on works so effectively. The second key principle or leg in the ‘‘three-legged stool’’ of my approach is its individualized design. We are all distinct human beings with our very own abilities to follow directions maintain a program and engage in physical activities. Each of us has his or her own tastes and food preferences work schedule lifestyle and recreational interests. In a doctor’s office we expect an individualized approach to our medical problems. For example I expect my physician to identify my problems specifically and to treat them accordingly. Otherwise I could just walk into any pharmacy and buy over-the-counter medications to treat my maladies. Occasionally we all do just that—but in most cases we want our doctors to do an examination to find out why we cough and to prescribe medications that are right for us. No two health problems are identical even though

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At the Beginning 7 many are alike. No two patients are the same either even though they may have similar problems or symptoms. We should not settle for anything less in the treatment of obesity and diabetes. The last and unfortunately weakest leg of this tripod is your own commitment to lifestyle changes my dear reader. This is where most weight-loss programs fail. As the May 2002 issue of Consumer Reports stated less than 25 of all dieters are able to keep their weight down for a year regardless of the diet they use. Your ability to stick with the plan is integral to your success in losing weight and keeping it off. The Draznin Plan is not a prescription for exercise. I am well aware that you are tired of being urged to exercise. I understand that you my reader cannot become an athlete or a

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8 Living with Diabetes spokesperson in a commercial for an exercise machine. Likewise my approach does not consist of a set of recipes. The last thing you need is more recipes. Your bookshelf is already sagging under the weight of many cookbooks. You are a normal living being—a reasonably active person who is not sweating in a gym or pedaling through miles of bike trails. You work you take care of your home and your family and you are mildly to moderately overweight. You wish to lose about 10 pounds and to drop one or two clothing sizes. You wish to get and stay healthy. All of us—or better said almost all of us—with rare exceptions love a hearty and tasty meal. Delicious and savory Eating should be a joy. food is both pleasurable and fun. Eating should be a joy. Eating out is frequently an event. Good breakfast defines our day. A lovely picnic with friends provides lively entertainment. An elegant dinner is a wonderful nightcap. A diet regardless of its composition is seemingly an antonym of good living. A diet is a drag a constant fight with guilt and frustration a

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9 Living with Diabetes perpetual struggle. Why then do I recommend it to you There is only one reason: to improve your health and possibly longevity. Only when you come to this very conclusion yourself will you be successful in maintaining ahealthydietprovidedthedietoffersvarietytaste and satiety. My program will empower you to be in charge of your weight—and your diabetes if you have it. It relies on simplicity long-term goals patience and adjustments. Realistic expectations will become your guiding principles. I am confident that my down-to-earth concept will help you change your lifestyle forever. Finally here comes the most important question you might ask: Why should I buy your book Dr. Draznin Excellent question. And here is my four-point answer. First and most

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At the Beginning 10 important my book offers practical commonsense advice that will allow you to adopt the Draznin Plan into your daily life so as to achieve and maintain weight loss as well as to treat and prevent diabetes. Second my book includes many real-life cases from my own practice skillfully disguised of course that will aid you in your quest for meaningful lifestyle changes. Third my book provides a scientific explanation for those who wish to explore it of how body weight is regulated and how we can therapeutically impact these regulatory mechanisms. Finally this book was written by a world-renowned authority on diabetes and metabolic disorders a professor of medicine at a major university one of the leading diabetologists in the United States and an author of many scientific articles book chapters and monographs in this field. You my reader should now be ready to embark on a journey toward a very different lifestyle and I or my book to be precise will be your skipper helping you maintain your new course. I offer what I believe is the most practical guide and the most realistic approach to your problems with

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At the Beginning 11 weight maintenance. Over 100 of my own patients have used my plan and more than 80 of them achieved their goals. Will you be next Sincerely Boris Draznin MD PhD An Introductory Case ‘‘I’m about fifty pounds overweight I have high blood pressure and my doctor told me I have a great deal of risk of developing diabetes’’ announced Mr. Jeffrey K. from his chair in my office. Jeff was six feet tall and weighed just over 230 lb. His shoulders slouched forward as he bent over his bulging belly. His left ankle rested over his right knee this was because he

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12 Living with Diabetes could no longer cross his legs owing to a protruding stomach. ‘‘In short’’ he continued after taking a deep breath ‘‘I’ve been welcomed to the club. This is the first time in my life I have to actively resist joining a club—a club of obese diabetics. Can you help me’’ Jeff was wrong. He wasn’t about to join this ‘‘exclusive’’ club—he had already joined it: a club of 28 million Americans who are overweight and 16 million Americans who have diabetes. His fasting blood-sugar level was 136 mg/dl milligrams per deciliter a full twenty-six points higher than the upper limit of the normal range in the diagnostic criteria for diabetes. Normal fasting blood-sugar levels range between 70 and 110 mg/dl. Fasting blood-sugar levels greater than 126 mg/dl define diabetes. Levels between 110 and 126 mg/dl are designated as ‘‘impaired fasting glucose.’’ Jeffrey K. was a forty-seven-year-old successful lawyer a ‘‘guru’’ in international business law with strong entrepreneurial skills. He spoke fluent French and some German and spent about 60 of his time in Europe and

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13 Living with Diabetes Africa attending to business deals. Hotel breakfast buffets business lunches and dinners had been his main diet for a number of years. Even at home he loved to take his family out to eat. He enjoyed ethnic foods and cold draft beer. The fact that he was gaining weight steadily was fairly obvious to him but Jeff didn’t like to think about it. A couple of times he had thought he should eat a bit less but he loved his food so much that the very idea of dieting was simply foreign to him. Jeff had never been very athletic but in his college days he had loved to play touch football and softball. He even thought he was quite good at these sports but he hadn’t done anything in the way of exercise since his days at law school. He knew that

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At the Beginning 14 many of the hotels where he stayed during his travels had health clubs but he had never ventured out to any of them. He didn’t feel like getting up early in the morning and he was too tired after a long working day to exercise in the afternoon. ‘‘Mr. K.’’ I replied politely but firmly ‘‘you do have diabetes. As you just pointed out you also have obesity the second largest preventable cause of premature death in this country. Only smoking causes more preventable deaths. There is a substantial probability that you can reverse your diabetes if you lose weight and return to a more active lifestyle. Not a guarantee but you have a great chance for success. ‘‘I have been doing research in diabetes and treating patients with diabetes and weight problems for more than thirty years’’ I continued. ‘‘These years of experience have allowed me to create and refine my own program and it has helped many patients like yourself change their lifestyles lose weight and prevent the development of diabetes.

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At the Beginning 15 ‘‘You will have to eat less than you do now’’ I stressed ‘‘and you will have to be much more active than you are now. I will teach you to exercise so that you will be able to walk up to three Draznin Miles a day and to eat up to eighteen Draznin Calories a day. I will also teach you where and what to eat when you dine out how not to be hungry and how to make physical activity a part of your life. ‘‘The only way I can be of help to you however is if you and I reach a contract which will require that you become an active participant in our efforts to restore your health. It won’t be easy and it won’t be quick. You and I will have to introduce a lot of changes into your lifestyle your attitude and your commitment to health. I will guide you but you will have to do the climbing to achieve our goal. I’ll shed the light but you’ll

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16 Living with Diabetes have to walk the path. There are plenty of difficulties and frustrations along the way. You won’t succeed unless you are totally dedicated to this goal. I cannot promise a cure but with your effort and commitment we will certainly make significant improvement in your health and consequently longevity. ‘‘Our success is in your hands’’ I concluded. Jeff listened attentively perhaps trying to guess what kinds of changes he would have to implement how much frustration he would have to endure how much commitment he would have to make and how much trust he would have to put in me and my program. ‘‘You are a successful businessman Mr. K.’’ I continued reading his thoughts in his expression. ‘‘The word ‘failure’ is not in your vocabulary. And the reason you don’t fail is very simple: It is because of your commitment to your business your adherence to your plans your perseverance in pursuing your goals and objectives your ability to take one step at a time making adjustments as you move along and your vision of the future. You and I both know that you

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17 Living with Diabetes have to possess these exceptional qualities to navigate in the business world. What we must do is apply the same qualities to your lifestyle exactly as you have applied them to your business. ‘‘I am going to offer you a set of rules. I don’t know whether you will live longer if you follow the Draznin Rules but I am certain that you’ll increase your chances for longevity and undoubtedly enhance the quality of your life.’’ For several moments we sat in silence looking straight into each other’s eyes. ‘‘You have three options’’ I said with a smile attempting to make it easier for Jeff. ‘‘You can leave this office right now and continue with your current lifestyle. You can spend an hour

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At the Beginning 18 with me hear my advice and do with it whatever you wish. Take it or leave it so to speak. Or you can decide to make a commitment to your own health and work with me to improve it.’’ Jeff pondered the options I offered him. We’ll return to his reply later in the book. Meanwhile let me tell you a little bit about myself and acquaint you with the Draznin Rules of life. The Origin of the Draznin Plan My interest in diabetes may have been aroused by my own family history. My grandfather my mother and a maternal uncle had type 2 diabetes. For over thirty years from the day I finished medical school I have been doing clinical and basic research in the field of diabetes studying insulin one of the hormones that helps to For over thirty years from the day I finished medical school I have been doing clinical and

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At the Beginning 19 regulate our weight and how to basic research in the field of diabetes . . . achieve the best control over this chronic disease. I have also been trying to find the best dietary regimen for my patients. In the process I have developed an approach to the problem of weight management that has been helpful to the majority of my patients. I developed the concept of the Draznin Mile in which the duration of activity rather than the actual distance covered is the measure of exercise. Later I added the concept of the Draznin Calorie in which any serving of food containing 100 calories is counted as one Draznin Calorie. Later in this book I will discuss the Draznin Mile and the Draznin Calorie in more detail so that you can begin to use these concepts in your own efforts to lose weight.

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20 Living with Diabetes Using this system and a dozen Draznin Rules of lifestyle I’ve developed over the years eight out of every ten of my patients were able to lose weight keep it down and prevent or get rid of their diabetes. This is an 80 success rate Now I am ready to share my approach with anyone who wishes to lose weight and rid him- or herself of type 2 diabetes.

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Chapter Two Our Weight in Numbers To Kill Diabetes Permanently Click Here He who would eat the kernel must crack the nut. Danish proverb he most amazing fact in the field of weight management is that the overwhelming majority of dieters in the United States do not need to lose weight yet many people who do not need to lose weight are trying to do so. The culturally driven perception of ‘‘self-image’’ governs a widespread belief that we must be one or two clothing sizes smaller than we actually are. In contrast only a small number of significantly overweight people— the ones who need to lose weight the most—are on diets. T

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This sounds like a paradox. Shouldn’t it be the other way around Shouldn’t overweight people diet The answer is yes of course but the fact remains—obese people are seldom on a diet. As we examine this apparent paradox a bit more carefully we will see the depth of the problem. The discrepancy is easy to understand after we learn that 95 of those who lose weight on any diet regain it within the next twelve to twenty-four months. Not surprisingly they give up on their diets. Frustration and denial replace drive and perseverance. 13

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23 Living with Diabetes A survey conducted by Consumer Reports on the efficacy of various diets revealed that only 3 of participants had managed to complete formal weight-loss programs in the preceding three years. Even among those who had finished the average success rate was only 26. This is less than one- third of the 3 of people who began dieting in the first place Demographically speaking obese individuals as a group have lower incomes and less education than do nonobese people and more frequently they remain single. The reasons for this are beyond the scope of this book but it is clear that obesity has a high personal cost even before taking into account the adverse health consequences of being overweight. Ideal Body Weight and Body Mass Index Because most of us in the United States a virtual ‘‘land of plenty’’ carry an extra layer of subcutaneous fat the question on everyone’s mind is ‘‘How much is too much’’ For years the answer was relatively simple—if your weight was 20 greater than your ideal body weight you were

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24 Living with Diabetes obese. With an answer like that one must immediately ask the follow-up question ‘‘What is the ideal body weight’’ The first attempt to define the ideal body weight came with the publication in 1959 of the Metropolitan Life Insurance Company tables. At that time the tables demonstrated that the risk of premature death increased along with increased weight. The desirable weight according to the Met Life tables was 126 lb 57 kg for a woman five feet four inches 1.63 cm tall and 154 lb 70 kg for a man five feet ten inches 1.78 cm tall. Today over 80 of the American public exceeds these standards. If you are a man or woman of medium build you can approximate or ‘‘guesstimate’’ your ideal body weight. To do

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Our Weight in Numbers 25 this women should count 100 lb for the first five feet of their height. Then they should add five pounds for each inch over five feet. For example a five-foot six-inch woman would calculate her ideal body weight as 130 lb 100 lb for the first five feet and 5 lb 6 ¼ 30 lb for the additional six inches. Medium-built men should count 106 lb for the first five feet and add six pounds for each additional inch over five feet. A reasonable guesstimate of the ideal body weight for a six- foot man is 178 lb 106 lb for the first five feet and 6 lb 12 ¼ 72 lb for an additional twelve inches. Subsequent studies showed that a ratio of weight to height defined as weight in kilograms divided by the square of the height in meters was a better surrogate for the risk of death from heart disease. This new ratio has come to be known as the body mass index or BMI. For those of us who think in pounds and inches the BMI can be calculated by dividing weight in pounds by height in inches squared and multiplying the quotient by 703. For example a man who weighs 200 lb and is seventy inches tall has a BMI of 29: 200 7 70 2 703 ¼ 200 7 4900 703 ¼ 28.7 or 29. Increases

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Our Weight in Numbers 26 in BMI were found to be associated not only with heart disease but with many other health con- ditions also. Today’s consensus not without complications is that a BMI greater than 27 confers a progressively increased risk of adverse Obesity is clearly associated with diabetes hypertension heart disease arthritis and gallbladder disease as well as cancer of the endometrium breast prostate and colon. health consequences see Table 2.1. Obesity is clearly associated with diabetes hypertension heart disease arthritis and gallbladder disease as well as cancer of the endometrium breast prostate and colon.

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27 Living with Diabetes Table 2.1 BMI kg/m 2 and the Risk of Death BMI Diagnostic Category 19–25 Normal weight 26–29 Overweight 30–35 Obese 35–40 Severely obese Over 40 Morbidly obese Sex BMI: Lowest Risk of Death Men 23.5–25 Women 22–23.5 Therefore one way of defining the ideal body weight is to say that only a weight not associated with adverse health consequences is ideal. For practical purposes this would be the weight that yields a BMI of less than 27. A BMI of 19–25 is accepted as normal. Those of us with a BMI between 25 and 29 are considered overweight and those with a BMI of over 30 are said to be obese. A BMI of 30 – 35 characterizes the moderately obese a BMI between

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28 Living with Diabetes 35 and 40 defines severely obese people and those with a BMI of over 40 are morbidly obese. The first important caveat in using the BMI to define obesity is the fact that some very muscular and athletic people have high BMIs but no negative impact on their health. That is because their increased weight reflects the weight of strong muscles and not excess fat. One of the best examples of the influence of muscle mass on the BMI was provided by Dr. Gary J. Davis of Evanston Hospital in a letter to the editor of the New England Journal of Medicine. Dr. Davis reported that basketball player Michael Jordan by many accounts the athlete of the century had a

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Our Weight in Numbers 29 BMI of 24 being 1.98 m tall and weighing 95 kg. This BMI placed Jordan on the less healthy end of the healthy-weight spectrum although his body-fat content was under 10. Even more striking the body-fat content of another NBA star Shaquille O’Neal is reported to be approximately 5 but his BMI is 29.7 2.18 m height and 141 kg weight placing him clearly in the obese category The second caveat is that at any given BMI individuals who are less fit have higher health risks than do their well- trained peers. In a study at the University of Alabama researchers found that unfit but thin men with low BMIs— 25 or lower—had twice the risk of death from all causes than did fit but overweight men with BMIs of 27.8 or greater. What this means is that the degree of muscle development and the state of fitness can greatly influence health risks outside the parameters of the BMI. Finally the distribution of fat in either the upper body apple-shaped obesity or the lower body pear-shaped obesity also confers different health risks with upper-body obesity being more closely associated with adverse health

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Our Weight in Numbers 30 consequences such as heart disease obesity and hypertension. Upper-body obesity can be detected easily by measuring the circumference of the waist. People who are forty years old and younger with a waist circumference over forty inches and those over forty years old with a waist circumference greater than thirty-six inches have significantly increased cardiovascular risk. Obesity Rates Are Climbing Around the world both body weight and the prevalence of obesity are increasing rapidly. Epidemiologists nutritionists and diabetologists firmly believe that we now live in an era of epidemic obesity. The Worldwatch Institute an Internet

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31 Living with Diabetes Table 2.2 Prevalence of Obesity Group Frequency of Obesity U.S. adults 55 Overweight 22 Obese U.S. children 22 Boys obese 25 Girls obese European adults 20 Overweight Watchdog group estimates that worldwide there are more obese than malnourished people. Today 15–20 of European adults and 50–55 of Americans are significantly overweight see Table 2.2. The National Health and Nutrition Examination Surveys carried out by the National Center for Health Statistics have shown that 22.5 of the U.S. population is moderately to severely obese BMI greater than 30 whereas some 55 of the total population is considered overweight BMI greater than 27. This is a startling jump from the 14.1 obesity rate between 1971 and 1974 and the 14.5 rate between 1976 and 1980. Today 63 of American men and 55 of American women have a BMI of 25 or higher indicating

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32 Living with Diabetes that more than half of U.S. adults are considered either overweight or obese. More than 1.1 billion adults worldwide are overweight and 312 million of them are obese. According to the International Obesity Task Force ironically it exists at least 155 million children worldwide are either obese or overweight. A look at some more recent data however offers an even gloomier picture. Interestingly and sadly the number of Americans who are about 100 lb or more overweight this is a severely obese group with a BMI of 40–50 grew by a staggering 50 between the years 2000 and 2005. This growth was

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Our Weight in Numbers 33 twice as fast as in the group of people with moderate obesity 24. But shockingly the fastest-growing group was that of people with extreme obesity: the number of Americans with a BMI of 50 or higher increased by an incredible 75 When the risk of death from all causes together—or from cancer or heart disease separately—was calculated as a function of weight it was found to increase substantially throughout the range of moderately to severely overweight individuals both men and women in all age groups. The lowest risk of death was found in men with a BMI of 23.5– 25 and women with a BMI of 22–23.5. The relative risk of death remained low until the BMI exceeded 27 in men and 25 in women. In people with BMI values greater than these the relative risk of death increased steadily. Recently the American Association of Retired Persons AARP issued a report on the health status of older Americans. It stated that even though ‘‘Americans over fifty are living longer smoking less and developing fewer disabilities increasing obesity could cancel the health gain.’’ The report also states that between 1982 and 1999

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Our Weight in Numbers 34 obesity nearly doubled among those over age fifty increasing from 14.4 to 26.7 . Equally impressive is an increase in the prevalence of obesity among children. In boys aged six through eleven the percentage of obesity increased from 15.2 to 22.3 be- tween 1963 and 1991 for girls the percentage climbed from 15.8 to 22.7. These numbers were steadily on the rise through the 1990s. Many pediatricians pediatric endocrinologists Many pediatricians pediatric endocrinologists and physicians working with adolescents have expressed genuine concern about the wave of obesity and even type 2 diabetes among children and young adults.

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35 Living with Diabetes and physicians working with adolescents have expressed genuine concern about the wave of obesity and even type 2 diabetes among children and young adults. As recently as ten to fifteen years ago type 2 diabetes was exceptionally rare almost unheard of in children and adolescents. The epidemic of obesity has changed this reality and introduced type 2 diabetes to a generation of our children. Why Are We Becoming More Obese The reason or more appropriately reasons for the dramatic increase in the prevalence of obesity are not completely clear. I cannot offer you a definitive answer—entire books have been written on this subject and researchers are still trying to puzzle out the complexities of this problem. What we do know is that obesity has a relatively strong genetic component—meaning we inherit some of the risk for obesity from our parents—even though the genes responsible for this specific obesity-prone background have not yet been identified.

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36 Living with Diabetes However the rapid progression of this epidemic cannot be explained by genetic influence alone. There is no reason to believe that there has been a recent major change in the genetic makeup of inhabitants of the Western world. We can assume that the propensity for obesity—the genes that predispose us to store energy and gain weight—must have been with us for generations. Recent changes in environmental factors must have had a huge impact in order for the incidence of obesity to explode as it has. To prove this point let’s consider the Amish. Obesity among Amish children is rare. A recent study compared the prevalence of obesity and the levels of physical activity in children from a rural Old Order Amish community with children living in modern society. Researchers found that only 7 of the Amish children were overweight and only 1.4

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Our Weight in Numbers 37 were obese. Among non-Amish American and Canadian children of the same age 25 were overweight and up to 9.5 of boys and 11.7 of girls were obese. The activity logs kept by the Amish children indicated that they performed multiple daily chores requiring considerable physical activity. They milked cows gardened fed farm animals and carried wood. What’s more most Amish children walk to school regardless of weather conditions. What this study tells us is that physical activity has an enormous impact on obesity. Physical activity is only half of the story. Our lifestyles have become more and more sedentary yes. But the increase in availability of food particularly of high–caloric density items constitutes another important change our society has experienced in the last two to three decades. I would like to draw your attention to an interesting relationship between the rise in obesity rates in the last fifteen years or so and historical changes in nutritional recommendations in the United States. In 1921 it was recommended that we consume 20 of our daily ration in

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Our Weight in Numbers 38 the form of carbohydrate. This figure gradually increased to 40 in the 1950s and to 45 in the 1970s. In the 1970s and early 1980s there was a tendency among nutritionists and diabetologists to consider carbohydrates especially refined sugars ‘‘pure white and deadly.’’ Such was the title of the book published by a British diabetologist Dr. J. Yudkin in 1986. Since then the perceptions of nutritionists and their attitudes toward carbohydrates have changed dramatically. Suddenly around 1985 or 1986 American nutritionists began advocating 60 carbohydrate in a healthy diet What we called the ‘‘prudent’’ diet of the 1990 s recommended that the food we eat contain 50–55 carbohydrate. Even though one cannot draw any solid conclusions about a cause- and-effect relationship a distinct parallel exists

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39 Living with Diabetes between the jump in carbohydrate consumption and the rise in obesity. Why did the experts in nutrition increase their advocacy for carbohydrates They did not mean to harm us. They did not wish to worsen the epidemic of obesity in this country. They recommended what they saw as the best eating strategy for a healthy lifestyle at that time. And yet they have created a problem that will take years to undo. First of all in my experience most of the well-meaning specialists in nutrition are also committed to strenuous exercise and heavy-duty workouts. They bike and run and they fill aerobic classes to capacity. They are constantly engaged in recreational activities and proudly display to the rest of us their slim muscular bodies dressed in sweat- drenched athletic attire. They need tons of extra energy to cover the expenditure that occurs during exercise and they find this readily available energy in high-carbohydrate food. They became and remain completely oblivious to the fact that most of us do not exercise at all They have blanketed us with the message of the benefit of a high-carbohydrate

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40 Living with Diabetes diet forgetting a simple truth: What’s sauce for the goose is not always sauce for the gander. While nutritionists and exercise enthusiasts were promoting their love for the high-carbohydrate diet scientists began to understand that cholesterol and other fats might have a detrimental effect on the heart and blood vessels. At the beginning no distinction was made between ‘‘bad’’ fat and ‘‘good’’ fat between the ‘‘Western’’ diet and the ‘‘Mediterranean’’ diet or between the influences of saturated and unsaturated fats. Fat in the diet became synonymous with a death sentence. This grew to the point where some parents withheld milk from their children in their zeal to eliminate fat from their offspring’s diets. The food industry willingly or unwillingly was also dragged into this craze. ‘‘Low-fat’’ and ‘‘no-fat’’ items filled the

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Our Weight in Numbers 41 shelves of supermarkets. The problem was that all that ‘‘nasty’’ fat was being replaced by huge amounts of carbohydrates Elimination of fatty foods and reduction in fat content might have had a beneficial effect as this would have reduced the total number of calories consumed but not when all those calories were simply replaced by carbohydrates. Poor reasoning inadvertently killed the good deed much like the proverbial road to hell that is paved with good intentions. Many food items particularly those that contain hefty doses of carbohydrates proudly display the ‘‘Food Guide Pyramid’’ on their labels. The base of the pyramid represents bread cereal rice and pasta—food choices recommended by the guide. For a sedentary individual this pyramid is not an ancient wonder but the best prescription to promote obesity Obesity and Its Relationship with Diabetes Obesity is not a trivial or innocent condition. Approximately 300000

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Our Weight in Numbers 42 Americans die every year from complications attributable to obesity. These complicationsconstitutethe second leading cause of preventable death in America Approximately 300000 Americans die every year from complications attributable to obesity. after complications from smoking. It is now estimated that one-third of all people born after the year 2000 will develop diabetes at some point in their lives. One of the most common conditions that accompanies obesity is type 2 diabetes. Obviously not all overweight or even severely obese individuals develop diabetes but the risk for the disease substantially increases with weight. Not surprisingly both incidence the number of new cases in a given time period and prevalence the total number of cases in a given

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43 Living with Diabetes population of diabetes increase in parallel with increasing rates of obesity. The relative risk of developing diabetes in individuals with a BMI of 24–25 is about 5. The risk doubles growing to 10 in those with a BMI of 27–29 and quadruples to 20 in those with a BMI of 29–31. The risk escalates further to 40 in people with a BMI of 33–35 and to an incredible 60 in individuals with a BMI greater than 35. Conversely statistics show that over 85 of patients with type 2 diabetes are obese. Each year approximately 800000 Americans are diagnosed with the condition. About 90 of these or 720000 have type 2 diabetes. If 85 of these newly diagnosed individuals are obese the country will acquire 612000 patients with diabetes and obesity annually. A slightly higher number of women have diabetes than men and the incidence of diabetes increases with age. On average African Americans and Latino/Hispanic Americans are almost twice as likely to have diabetes as are Caucasians of similar age. We don’t know exactly why this is although the reason most likely has to do with genetic differences

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44 Living with Diabetes between ethnicities. It is estimated that in the United States approximately 25 of all adult patients with type 2 diabetes belong to minority groups. The rate of death—from any cause—among middle-aged people with diabetes is twice as high as that for middle-aged people without diabetes. For example the relative risk of heart attack is 50 greater in diabetic men and 150 greater in diabetic women than in their nondiabetic counterparts. Diabetic men are 50 more likely to die suddenly sudden death is mainly due to heart attack or stroke than men in the general population. For women the disparity is even greater with sudden death being 300 more common in diabetic than in nondiabetic ones.

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Our Weight in Numbers 45 Both obesity and diabetes are closely associated with heart disease mainly atherosclerotic coronary artery disease which can lead to heart attacks chest pain angina and stroke. Problems with atherosclerosis in patients with diabetes and/or obesity begin with what is called ‘‘inflammation’’ in the blood vessel walls. This inflammation is marked by the appearance of a protein called C-reactive protein CRP. The greater the inflammation the more CRP is found in the blood. Recent studies indicate that consumption of food items with high concentrations of rapidly absorbed carbohydrates results in substantial increases in the appearance of CRP in blood in apparently healthy middle-aged women. These findings suggest that intake of such foods may increase the risk not only of diabetes but of atherosclerosis and heart disease. Poorly controlled diabetes triggers numerous other complications and medical problems. Almost half of new cases of end-stage kidney failure leading to either dialysis or kidney transplantation are related to diabetes. Most patients with diabetes suffer nerve damage after fifteen to twenty

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Our Weight in Numbers 46 years with the disease. Diabetes is also a leading cause of nontraumatic leg amputation 82000 cases in 2002 according to the Centers for Disease Control and Prevention www.cdc.gov and approximately 20 of male patients with diabetes complain of impotence. In the United States diabetes is a leading cause of new cases of blindness among people twenty to seventy-five years of age in 2002 there were 24000 new cases of blindness attributable to diabetes. Eye disease particularly problems with small blood vessels of the background of the eye known as the retina is a very common complication of diabetes. These little conduits of blood can grow uncontrollably and break causing retinal detachment and severe bleeding inside the eye. Increased fluid pressure within the eye glaucoma and damage to

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47 Living with Diabetes the optic nerve the main nerve of the eye that transmits the image from the retina to the brain can also occur with increased frequency in diabetes. It is not surprising that a problem of such magnitude is on the minds of thousands of Americans who are eager and almost ready to turn the tide of obesity In the chapters that follow you will be introduced to the details of the Draznin Plan . . . in this country. That’s where this book comes in. In the chapters that follow you will be introduced to the details of the Draznin Plan along with the guidance and information you will need to implement my weight-loss strategies to avoid the dangers of obesity and to prevent or treat diabetes.

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Chapter Three The Law of Conservation of Energy To Kill Diabetes Permanently Click Here espite amazing advances in the biomedical sciences physicians and scientists do not really know why some of us gain weight so easily while others eat just about everything they see the ‘‘see-food diet’’—you see food you eat it and remain slim. We also have very little D

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information about why some of us overweight creatures develop diabetes while others equally overweight do not. Much of the reason is probably genetic our vulnerability to obesity and diabetes determined by the genes we have inherited from our parents. Therefore the first Draznin Rule is as follows: The most important step in life is to choose your parents correctly. If one were to follow this rule and it isn’t easy and do it well the rest would simply fall into place. One . . . the first Draznin Rule is as follows: The most important step in life is to choose your parents correctly. would neither be overweight nor develop diabetes. However the genes that determine whether we are destined to become overweight seem to be extremely prevalent and to occur with great frequency. It is 27

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50 Living with Diabetes safe to say that the majority of us given unlimited access to food have a tendency to gain weight. Centuries ago when our food supply was erratic and predictably unpredictable the genes that allowed our ancestors to store more fat and thereby more energy were beneficial to our survival and as such spread among the population. Today in a time of plenty these genes are more than just a nuisance and we have to fight their fat-storing influence on an almost daily basis. Energy Consumption and Expenditure Energy is the most fundamental requirement for all aspects of life. For any biological process to occur an organism whether it is a single-cell alga or a complex mammal must possess enough energy to cover the demands of this process. The very survival of the organism depends on finding and acquiring appropriate quantities of energy to sustain life. However if an organism acquires more energy than is necessary to cover its needs excess energy is stored within

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51 Living with Diabetes the body and used appropriately when new energy intake is limited. Let us digress for a moment and examine what determines our ability to accumulate fat. Most of us have heard about the law of conservation of energy even though just a few of us truly understand it: energy we consume ¼ energy we expend If we consume more energy than we expend excess energy will be retained and stored by the body and the equation will look like this: energy we consume energy we expend ¼ energy we retain

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The Law of Conservation of Energy 52 The energy we expend consists of three parts: the basal metabolic rate the energy we expend to support physical activities and the energy we expend to support miscellaneous functions of the body we don’t really know where it The basalmetabolicrate or BMR . . . is the amount of energy required to support the work of the heart brain lungs and other organs at rest in the absence of any physical or mental exertion. all goes. The basal metabolic rate or BMR also known as resting energy expenditure is the amount of energy required to support the work of the heart brain lungs and other organs at rest in the absence of any physical or mental exertion. The BMR accounts for approximately 50–65 of our total daily energy expenditure. The energy we expend on physical activity is called activity thermogenesis or AT also known as voluntary energy expenditure while the third component of energy expenditure is known as non- exercise-associated thermogenesis or NEAT the amount of energy we spend fidgeting.

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The Law of Conservation of Energy 53 Finally a small amount of energy is spent on breaking down digesting and absorbing food the biochemical conversion of nutrients during the metabolic cycle and the production of new energy. This looks like an investment in a process that generates much more energy in return. This expenditure is called the thermic effect of food or TE and it accounts for about 10 of the total daily energy expenditure. Therefore: calories consumed ¼ BMRþATþNEATþTE The term ‘‘calorie’’ as used in this book represents 1000 calories or 1 kilocalorie 1 kcal. See Chapter 10 for the

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54 Living with Diabetes scientific definition of ‘‘calorie.’’ Again if we expend less than we consume the remaining energy will be stored: calories consumed ¼ BMRþATþNEATþTE þcalories in storage weight gain Conversely if we expend more than we consume we will lose energy from storage and lose weight: BMR þATþNEATþTE calories consumed ¼ calories removed from storage weight loss With food being the only energy source for creatures like us the mouth is the only loading dock for delivering energy supplies to the body. We know that ‘‘man does not live by bread alone’’ and yet food is our only source of energy. If we expend almost all the energy we consume very little will be left over to store. In other words the energy that remains in the body at the end of the day is the difference between the energy we have obtained from food and the energy we have spent during that day. Roughly each time the amount of energy consumed exceeds the amount of energy spent by

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55 Living with Diabetes approximately 3500 calories we gain one pound of fat. This means that just a little over 500 calories per day in extra food will be converted into a pound of fat in a week. This equation 3500 calories ¼ 1 lb of fat is important to remember not only because of its negative connotation but also for your future success in losing weight. A deficit of 3500 calories will result in a one-pound weight loss. The second Draznin Rule is as follows: If longevity is in your The second Draznin Rule is as follows: If longevity is in your genes the quality of your life is in your hands. genes the quality of your life is in your hands. Predisposition to type 2 diabetes is defined by the genes we inherit from our parents. Some of these genes

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The Law of Conservation of Energy 56 remain silent until environmental influence such as weight gain reveals their presence. For example as I gain weight and become more and more insulin-resistant my pancreas must produce more and more insulin to overcome the resistance to this hormone my body builds. However my pancreas is genetically programmed to produce only a certain amount of insulin and cannot keep up with the demands imposed by my weight gain. Because of these genetic limitations at a certain point my pancreas will no longer be able to meet the demands and my predisposition to diabetes will convert into overt disease. How Calories Are Absorbed or Not The law of conservation of energy is indisputable unshaken by any doubts and it remains the basis for our understanding of weight gain and weight loss. But the law comes with caveats. Nothing in life is as simple as it appears to be. First not all the food that enters our mouths is consumed by our bodies and utilized as calories. Some of this food is never absorbed. It passes through the gastrointestinal tract and is

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The Law of Conservation of Energy 57 expelled at the other end. Let us assume that two individuals Mr. A. and Mr. B. have each eaten a bowl of cereal containing 300 calories of energy. That day Mr. A. had diarrhea. We do not know at this point why he received an urgent call to the bathroom—maybe he just returned from a trip to a foreign country traveler’s diarrhea or maybe he had lactose intolerance or some other medical problem. Regardless of the cause of his diarrhea he will absorb only part of the 300 calories he consumed. He will certainly have consumed fewer calories than Mr. B. who has no gastrointestinal problems. Now this is an extreme example— in real life there is a spectrum of levels of food absorption among people aside from that caused by diarrhea or constipation. Variations are numerous. Chances are good that you

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58 Living with Diabetes and your spouse for example do not absorb exactly the same numbers of calories even after eating exactly the same meal. This is just a fact of life that arises from our distinct genetic makeup and body composition. The second important variable in food absorption stems from the fact that certain foods are absorbed much better and faster than others. For example a teaspoon of sugar is absorbed almost instantaneously whereas a teaspoon of pasta requires significantly more time for digestion. The complex carbohydrates of pasta must first be broken down by the digestive system into simple sugars then they are absorbed. In contrast each molecule of table sugar consists of only two simple sugars that are readily absorbed. It is not surprising then that we absorb 8 oz of ice cream much faster than 8 oz of filet mignon. Recently new therapeutic strategies have been developed in an attempt to modulate food absorption and thereby influence caloric consumption. The class of drugs called ‘‘alpha-glucosidase inhibitors’’ blocks the breakdown of complex carbohydrates into simple sugars. Complex

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59 Living with Diabetes carbohydrates are not absorbed in the small intestine but instead moved down through the intestine to be evacuated. If you were to eat a plate of pasta while taking these drugs only a portion of what you ate would be absorbed. A great deal of your pasta would escape breakdown and absorption and would be eliminated. Similarly the drug orlistat blocks the activities of enzymes that help absorb dietary fats. Therefore when you take orlistat only a fraction of the dietary fat that found its way into your mouth will be absorbed and consequently stored by the body. This pharmacological tinkering with natural absorption is not without side effects. When carbohydrate breakdown in the small intestine is impaired by drugs the carbohydrates move to the large intestine where local microbes which love to de-

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The Law of Conservation of Energy 60 compose carbohydrates have a field day. While the microbes proliferate and digest as many carbohydrate molecules as they can find they also create a lot of gas in the large intestine. Gas has a natural way of escaping which may place a person taking these drugs in an untenable position. Furthermore since orlistat blocks fat absorption unabsorbed fat may slide down into the large intestine it may even leak out of the body often uncontrollably. These side effects are usually minor and create only minimal inconvenience but occasionally they can push a person into social isolation. How Calories Are Utilized or Not Absorption and consumption of calories differ among individuals what’s more once these calories are absorbed their utilization can vary dramatically from person to person. Let us return to our friends Mr. A. and Mr. B. Mr. A.’s diarrhea has now passed and he and Mr. B. each eat two slices of pizza about 700 calories per piece for a total of 1400 calories.

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The Law of Conservation of Energy 61 By the time they finish it is about 10:00 PM. Mr. A. and Mr. B. are equally physically active. They both go to sleep. Their bodies use the newly acquired energy to support their breathing food digestion heart and brain activity urine production all these bodily systems work on even as they sleep and occasional movement during the night turning and tossing in bed. Their bodies expend a sizable amount of energy to cover their basic metabolic needs the BMR. It turns out that because of differences in their genetic makeup these two men have very different BMRs. Metabolically speaking Mr. A.’s body is extremely efficient. He requires half the energy that Mr. B. requires to support his metabolic needs. While he is asleep his body uses only 800 calories leaving 600 calories 1400 calories – 800 calories ¼ 600 calories for storage and

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62 Living with Diabetes future use. In contrast Mr. B.’s body is exceptionally inefficient and he has had to use 1100 calories to support his basic metabolic needs. This means that he has only 300 calories left for storage and future use 1400 calories – 1100 calories ¼ 300 calories. Not surprisingly Mr. B. will not gain as much weight as Mr. A. even though they both ate exactly the same amount. When they wake up and go to the local health club to work out they will discover an interesting detail. In the absence of physical activity Mr. A. burns fewer calories than does Mr. B. Therefore Mr. A. will have to exercise almost twice as much as Mr. B. in order to reduce to the same degree the amount of energy he stores. Insulin Levels and Activity There is one more important concept that Mr. A. and Mr. B. and the rest of us should know about when considering

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63 Living with Diabetes ‘‘individualized’’ ways of utilizing calories. The way our calories are directed to either storage or utilization is under the constant and rigorous control of mone as well as its abil- The way our calories are directed to either storage or utilization is under the constant and rigorous control of insulin a hormone responsible for the maintenance of normal levels of glucose blood sugar in the blood. insulin a hormone responsible for the maintenance of normal levels of glucose blood sugar in the blood. The activity and levels of this hor- ity to work are critically important for the utilization of glucose by muscles and fat for energy storage in both the liver and muscle and for the growth and development of new and old fat cells in the body.

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The Law of Conservation of Energy 64 The latter is particularly important to understand. One cannot accumulate fat and become overweight in the absence of insulin. People who develop insulin deficiency so-called type 1 diabetes lose weight very rapidly in a process called lipolysis which is an accelerated breakdown of fat cells. We will return to insulin later in this book but for now it will suffice to say that both the levels and the activity of insulin represent the third important variable that modifies the law of conservation of energy in the human body.

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Chapter Four The Draznin Mile: A New Concept of Exercise To Kill Diabetes Permanently Click Here t is no secret that most of us do not like to exercise. Hence the third Draznin Rule is as follows: Desire to exercise is inversely proportional I

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. . . the third Draznin Rule is as follows: Desire to exercise is inversely proportional to age. to age. Healthy preschoolers almost without exception are remarkably active. Chasing your three- or four-year-old offspring can be an exhausting full-time job. By the end of grade school however the vast majority of children stop running skipping and jumping. The average American child now spends three hours a day in front of the TV set and at least one and a half hours a day in front of the computer. In junior high school physical education class is considered boring by at least 75 of students. At the same time four basic food groups emerge as the staple diet of teenagers: fast food soft drinks candy and sugar-coated cereals. By the age of thirty only a tiny minority of individuals engage in regular exercise. For those over thirty sport is now a spectacle—something we view from a chair a sofa

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or bleachers. At the age of forty we enter a period of life known as 36

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The Draznin Mile 68 ‘‘middle age.’’ By the way ‘‘middle age’’ is best defined as your own age dear reader and younger. In addition to the plethora of well-described peculiarities attributed to middle-age crises many middle-aged men and women make a feeble attempt to return to an active lifestyle. This attempt is almost never successful and rarely lasts longer than a year. A notable exception is the good tennis player. Tennis players tend to stay active longer usually until their knees can no longer take the abuse. Golfers who classify their game as exercise particularly those who drive electric carts indulge in self-deception. For most of us it is much more pleasant to lie by the pool with a good book in our hands after a quick five- to ten- minute dip than to swim multiple laps for an hour. In my neighborhood over 80 of the houses have a basketball hoop but in the last five years I have not seen a single neighbor over forty shooting hoops I have seen a few of my forty-plus neighbors jog. But the grimaces on their faces as they return home reveal both the misery and the displeasure caused by this form of exercise. Recently biking

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The Draznin Mile 69 particularly family bicycling has come into vogue. For a while I felt very encouraged by seeing a family of four or five on the bike path but it appears that most people give up biking as a form of exercise as soon as their teenage children stop riding with them. The truth of the matter is that unlike competitive sports where the goal is to be first by definition the strongest and the best exercise for the sake of sweating in the name of longevity is simply contrary to human nature. Having said all this I wish to proclaim that exercise is the single most important element for living a healthy life. The right amount of physical activity makes us feel better helps keep weight down supports our aging backs allows for better circulation and beefs up our ability to cope with stress. The

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70 Living with Diabetes question is how can we incorporate the right amount of exercise into our lives into our daily routines How can exercise become one of the basic activities of daily living such as bathing dressing eating and so forth If we who have an inherited aversion to exercise could only find a way of making exercise an integral part of our lives we would lose weight reduce blood pressure remove at least 80 of our tension and anxiety defeat diabetes in most cases live longer and feel better. Understanding the Draznin Mile Years of searching for a ‘‘magic recipe’’ for exercise have finally paid off with the invention of the Draznin Mile. Here is my formula: Walk three to four Draznin Miles each day or jog three Draznin Miles every other day. The Draznin Mile is the simplest way to measure your exercise. What is a Draznin Mile you ask Here’s how it works: The Draznin Mile defines the duration of your exercise—not the distance and certainly not the speed. Ten minutes of jogging or twenty minutes of walking equals one Draznin Mile. If you

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71 Living with Diabetes have jogged for ten minutes you can call it a Draznin Mile. If you have jogged for twenty minutes you have done two Draznin Miles no matter what the actual distance was. The distance is totally irrelevant. Never never never worry about the distance. The time is what is important. If it so happens that you have indeed jogged one mile in ten minutes you are doing much better than expected. A tenminute mile means that you can cover six miles in an hour. Please never even think of doing that You don’t need it. No one needs it. All you need to do is three Draznin Miles meaning a thirty-minute jog. If your weight is 175 lb with a jogging speed of ten minutes per mile you will burn eleven calories per minute or 330 calories in thirty minutes.

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The Draznin Mile 72 Do you see how easy it gets If you jog two Draznin Miles you burn 220 calories. In real life however for ordinary people like you and me the speed is totally irrelevant. Thus the fourth Draznin Rule is as follows: A ten-minute jog covers one Draznin Mile and burns . . . the fourth Draznin Rule is as follows: A ten-minute jog covers one Draznin Mile and burns 110 calories. 110 calories. I recommend that you jog at least three Draznin Miles every other day. Doing that you will burn 330 calories every other day or about 1000–1200 calories per week. There are two things I want you to keep in mind however. The first is the intensity of exercise. Intensity level is not important at all when you first embark on my program. In the beginning the most important point is to engrave a habit of exercising firmly into your daily life. At this stage the critical element of my program is to incorporate physical

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The Draznin Mile 73 activity into a new lifestyle. Later on the intensity will become a significant issue to consider. Low-intensity exercise is basically equivalent to the basal metabolic rate BMR in terms of energy expenditure. This is why light gardening and cooking do not help in losing weight. One is active all right but the intensity of the activity is too low to burn excess energy. The intensity of exercise must be at least moderate so as to expend energy over and above the BMR. Exercise physiologists call this ‘‘exercise at 65 or 75 of maximal capacity determined by your heart rate and oxygen consumption.’’ I can assure you however that if you do three Draznin Miles a day at least five days a week you will reach the necessary intensity to achieve your goal. The second thing to keep in mind is your gender. I guess that rarely escapes our minds. What I really mean is that there is a

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74 Living with Diabetes significant gender-dependent difference in energy expenditure particularly at the tender ages of fifty-five and over. In order to burn 300 calories a sixty-five-year-old man must exercise for approximately forty minutes. In contrast a sixty-five-year-old woman may have to exercise for seventy minutes to burn the same 300 calories. Whether or not this difference is related to loss of estrogen function during menopause is unknown but the fact remains— women must exercise longer at the same level of intensity to burn the same number of calories as men do. Now what if you cannot jog Not to worry. This is just fine. The Draznin walking mile is what you cover during a twentyminute walk. In other words if you have walked for twenty minutes you have covered a mile. Your actual speed if you indeed were to cover one mile in twenty minutes would be three miles per hour or half a mile in ten minutes. At that speed you burn 5.55 calories per minute. But as with jogging the actual distance is irrelevant. The Draznin Mile is a twentyminute walk so if you walk for forty minutes you have done two Draznin walking-miles and burned 220 calories. Not bad After a sixty-

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75 Living with Diabetes minute walk you The fifth Draznin Rule is as will have lost 330 calories. The fifth Draznin Rule is as follows: follows: A twenty-minute walk A twenty-minute walk covers covers one mile and burns one mile and burns 110 calories. 110 calories. It is easy to see that if you jog or walk a Draznin Mile ten or twenty minutes respectively you will lose approximately 110 calories. I recommend that you walk for sixty minutes at least five days a week. You can do it in one walk or split it into two

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The Draznin Mile 76 sessions: a walk in the morning and one in the evening. Your goal is to do three Draznin Miles every other day if you are a jogger or three to four Draznin Miles every day if you prefer to walk. Then when you talk with your friends or relatives or colleagues you can proudly say that you are doing three or four Draznin Miles either every day or every other day. They will be duly impressed and you will truly be doing a great favor for yourself. Getting Started This is your goal but you should start on a much smaller scale. Common sense never hurts. As far as I am concerned common sense dictates starting with a short five-minute walk. Just stroll out of your house and walk for five minutes along the straightest segment of the road in front of your dwelling. Walk five minutes by your watch. That would certainly mean that you would need another five minutes to return home. So take a deep breath and continue toward home. Congratulations You have just done a ten-minute walk and covered half a Draznin Mile. If you cannot walk

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The Draznin Mile 77 for five minutes in each direction you have a serious problem. This book is unlikely to help at this stage. Remember that your goal is to walk three to four Draznin Miles. You are not that far off. By the second week you should increase the time you walk in each direction to ten minutes for a total of twenty minutes of walking—and that is a Draznin Mile This is what you should do for the entire week. Increase the amount of time you walk by two minutes per week and five weeks later you will be walking two Draznin Miles a day or twenty minutes equal to one Draznin Mile in each direction. Do that for an entire month. Do not skip a single day. I want you to do a month of two Draznin Miles per day. In so doing

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78 Living with Diabetes you will expend 220 calories a day in addition to your normal daily energy expenditure. At the end of the month you will have two options: You can continue increasing your walking time and distance by two minutes a week until you are doing three Draznin Miles per day or you can start walking in the evening before or after dinner and build your evening walk up to one or two Draznin Miles. Some of my patients have honestly complained and not without reason that walking is inordinately boring. Fifteen or twenty minutes might be okay but anything beyond twenty to twenty-five minutes becomes a difficult chore. Fortunately electronic engineers have invented the Walkman the Discman the iPod and other listening devices that are exceptionally helpful in this regard. Just turn on your favorite radio program or CD or cue up your favorite play list and begin your march. Instead of listening from your couch to the click and clack of National Public Radio put on your earphones and go for an hour’s walk while still enjoying your favorite recording artist or composer. You

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79 Living with Diabetes will find that the boredom of walking will vanish with the first musical chords. I even have patients who listen to books on tape while walking. I just hope this does not replace their reading hour By the way if you decide to use a treadmill at home consider placing it in front of a TV set. Most of my patients watch TV at least thirty minutes a day being addicted to the local and national news various news-related programs and other shows. I recommend that they watch TV while walking a couple of Draznin Miles and many do. I must admit—I do it myself If you opt for jogging and have never exercised before you should start with a two-minute jog each way. Even though it sounds

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The Draznin Mile 80 like nothing this is the best way to get into the routine. As with walking you should add two minutes of jogging in each direction every week until you are jogging three Draznin Miles comfortably every other day. Congratulations once again— you have reached your goal Finding Alternative Forms of Exercise Before we end this chapter there is one more point to discuss. One day I spent a full hour outlining an exercise program for a patient Ms. J. only to learn at the end of our conversation that she cannot walk She had had frequent dislocations of her ankle and could not really undertake the risk of daily walking. So we turned to alternatives. The first alternative is swimming. It is a lovely form of exercise for good swimmers. Unfortunately I have found that for most of us it is not a good option. There is not enough muscular work in leisurely noncompetitive swimming. Most people get tired because of labored breathing long before their muscles have expended sufficient amounts of energy. But if

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The Draznin Mile 81 swimming is your only option a twenty-minute swim equals one Draznin Mile. Three Draznin Miles every other day is all you need The second alternative is bicycling. This form of exercise is much better but one must use a stationary bike and not a street bike. Not all of us feel comfortable on a street bike this is true not only on the street but even along bike paths. As a rule people who are significantly overweight do not have the agility necessary to ride a bike. Finally bike riding carries an inherent danger of falling which is better avoided. The problem with either a street bike or a stationary one is that riding without resistance is very inefficient in terms of burning energy. One has to spend much more time on a bike to achieve the level of energy expenditure

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82 Living with Diabetes that one would attain per unit of time jogging. Therefore if you must be on a bike thirty minutes of nonstop pedaling without resistance equals one Draznin Mile. To do three Draznin Miles you will have to pedal for ninety minutes. However that can be rather boring. One can increase the effectiveness of bicycling by either choosing programs with more resistance or doing uphill rides. In any event biking can be a viable alternative to jogging or walking Table 4.1. A word of caution for those who are actually preparing to buy new walking shoes: Anyone over the age of thirty-five or whomighthaveamedical care physician can refer Anyone over the age of thirty-five or who might have a medical condition particularly a heart problem must undergo a stress test before embarking on an exercise program. condition particularly a heart problem must undergo a stress test before embarking on an exercise program. Your primary

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83 Living with Diabetes you to a specialist to perform this test. This is a simple but extremely important precaution that should not be overlooked. People who have already developed complications of diabetes should be extremely careful with their exercise regimen. This is particularly true for those with diabetic retinopathy problems with the blood vessels at the back of the eye kidney Table 4.1 Draznin Mile Equivalents One Draznin Mile equals 1. 10 min jogging or 2. 20 min walking or 3. 20 min swimming or 4. 30 min biking without resistance and burns approximately 110 calories. Three Draznin Miles a day will allow one to burn 330 calories.

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The Draznin Mile 84 disease and heart conditions. They should not be doing weight lifting jogging or boxing. Walking and swimming are the most appropriate forms of exercise for these individuals. Assuming you have none of these problems within four to six months you should make three Draznin Miles your daily routine.

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Chapter Five Insulin Production and Storage of Energy and Regulation of Weight To Kill Diabetes Permanently Click Here believe a little dose of science is in order at this point. I subscribe to the theory that the more people understand about their medical conditions and the way their bodies work the greater the chances for successful therapeutic interventions. This is particularly applicable to the health I

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problems that require lifestyle changes. Having said this I acknowledge readily that not everyone is interested in the science underlying his or her medical problems. I would This chapter is here to make the scientific background of insulin energy and regulation of weight available to those who wish to learn more. not be affronted at all if you decide to skip this chapter entirely or return to it later after finishing the rest of the book I hope you’ll do the latter. This chapter is here to make the scientific background of in- sulin energy and regulation of weight available to those who wish to learn more. Insulin is undoubtedly one of the most important hormones in the human body. A protein produced in the pancreas a gland located in the upper part of the abdomen insulin is 46

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Insulin Energy and Weight Regulation 87 released into the bloodstream in response to sugar. Without insulin a person usually cannot survive more than a couple of weeks—seldom as long as a couple of months. This condition of complete or almost complete lack of insulin is known as type 1 diabetes mellitus. The only hormone in the body that reduces blood-sugar levels insulin Is produced in the pancreas Is released in response to meals Stimulates utilization and storage of sugars Stimulates formation of new fat and proteins Prevents breakdown of fat and proteins Is absolutely required for survival Type 1 diabetes most commonly occurs in children and young adults hence it was formerly known as ‘‘juvenile- onset diabetes’’ but it can appear at any age. It is believed to be an autoimmune disease wherein an unknown trigger commands the body to destroy its own insulin-producing

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Insulin Energy and Weight Regulation 88 cells. Synthetic insulin is a life-saving treatment for patients with type 1 diabetes. When we ingest carbohydrates they are broken down into simple sugars mainly glucose as they pass through the small intestine. Glucose is then absorbed into the bloodstream and this glucose-enriched blood flows immediately around the pancreas stimulating the release of insulin. Even though other factors also contribute to the release of insulin the rule of thumb is that the more sugar we consume the greater the amount of insulin is released to help utilize this sugar. Glucose in the Body Utilization of glucose generally means two things: to produce energy to support bodily functions and to store excess glucose

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89 Living with Diabetes for future use. The body is amazingly efficient in this process. It will utilize only what it needs to cover its energy expenditure. Whatever is left over please recall the law of conservation of energy will be stored under the watchful eye of insulin. Excess glucose can be stored in two ways. First molecules of glucose can be linked together forming the glucose-storage depot glycogen. Second when the glycogen stores are fully replete the remaining molecules of glucose can be converted into fat to be stored in fat tissue. It would be okay to store energy today for tomorrow’s use—for a rainy day so to speak. The problem is in the land of plenty this rainy day will never arrive. We continue to consume food and therefore energy in excess of our needs on a daily basis. As we consume more and more beyond what we can expend insulin will gladly do its job—stimulate the storage of more and more glucose and fat in the body. Glucose is stored in the liver and in the muscle but fat . . . oh boy don’t we know where that is stored

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90 Living with Diabetes The sixth Draznin Rule is as follows: What doesn’t kill makes fat This is actually an old South African proverb that was conveyed to me by a The sixth Draznin Rule is as follows: colleague an excellent en- What doesn’t kill makes fat docrinologist and a native of South Africa Dr. Mer- vyn Lifschitz. I have adopted this saying as an important rule. Insulin is a life-saving hormone for people with type 1 diabetes but in everyone else it helps produce fat Luckily there is at least one way to minimize the damage. One should and actually one must limit the amounts of carbohydrates especially pure refined sugars in the diet. If less sugar reaches the pancreas less insulin will be released and less energy will be stored as either glycogen or fat.

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Insulin Energy and Weight Regulation 91 In contrast to patients with type 1 diabetes who suffer from insulin deficiency some people with diabetes have enough insulin but it just doesn’t work properly. These people require greater amounts of insulin to achieve normal utilization of glucose by their organs and tissues. These individuals are said to have an ‘‘insulin resistance.’’ In other words their ability to utilize glucose as an energy source in response to insulin is reduced. Therefore they require additional output of insulin to maintain normal levels of sugar in the blood. At some point these patients fail to produce enough insulin to achieve this goal and they develop type 2 diabetes mellitus see Table 5.1. The fact that insulin is needed to ensure normal utilization of glucose is well known to the public. What is much less known and remains almost unappreciated is what insulin does in the metabolism of proteins and fats. Without insulin proteins in muscle break down into individual amino acids weakening the musculoskeletal system. At the same time

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Insulin Energy and Weight Regulation 92 Table 5.1 Two Types of Diabetes Type 1 Usually an autoimmune destruction of pancreatic beta cells with a resultant insulin deficiency. Frequently begins in childhood and in young adults and insulin treatment is mandatory for survival. Approximately 10 of all patients with diabetes have type 1. Type 2 The cause of this most common form of diabetes is unknown. It frequently begins in adulthood primarily in individuals who are overweight. It is characterized by inefficient action of insulin insulin resistance and inadequate insulin release. Approximately 90 of all patients with diabetes have type 2.

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93 Living with Diabetes stored fats break down into individual fatty acids and leak out—melting as it were. A person with a complete lack of insulin rapidly loses weight as a result of the accelerated breakdown of proteins and fats. Without insulin fat cells will not develop and those cells that have developed previously will lose their fat In other words none of us would be able to gain fat mass in the absence of insulin. Conversely we can only increase our weight if we have sufficient amounts of insulin in our circulation. Even though insulin is critically important it is not the only hormone involved in the regulation of weight. Several other hormones and chemical substances in the body help regulate appetite satiety and weight maintenance. These include leptin neuropeptide Y the melanocortins ghrelin and orexins A and B to name a few. Their presence and their influence also indicate that our expectations of finding a single medicine that will cure obesity in all overweight individuals may not be realistic. There are simply too many factors that influence our ability to gain lose and maintain weight. Instead interventions directed at multiple targets in

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94 Living with Diabetes the complex world of energy balance may be more appropriate and are more likely to be successful. Signals of satiety and hunger and of thinness and fatness are brought to the brain from the peripheral tissues after being generated in the stomach liver gut pancreas and fat cells. A very specific area of the brain a small region known as the ‘‘hypothalamus’’ has been recognized for some time as being responsible for both satiety and eating behavior. In fact one of the most important hormones leptin is produced in fat cells which collectively constitute one of the largest organs in the body. The word ‘‘leptin’’ comes from the Greek word leptos meaning thin. Leptin is a small peptide that appears to decrease

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Insulin Energy and Weight Regulation 95 appetite and to increase metabolism. Don’t we all wish to have more leptin in the body Like other peptide hormones leptin binds to a brain receptor present in the hypothalamus exerting its influence on the so-called brain satiety center. Leptin’s interaction with its receptor signals to the brain that the body has had enough to eat and as a result the appetite the sense of hunger decreases. In the overall picture the more fat cells a person has the more leptin should be produced and the greater the inhibition of appetite should be. In reality however it is not always the case. Many obese people have high concentrations of leptin in their bloodstream but their appetite is not decreased at all. This paradoxical constellation is known as a ‘‘resistance’’ to leptin’s action. The causes of this resistance are still unknown. In the hypothalamus signals arriving from the body are processed and integrated into various brain centers. The molecules that participate in this process are called ‘‘neurotransmitters’’ as they transmit appropriate information from one brain center to another. One of the

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Insulin Energy and Weight Regulation 96 most important signals is transmitted by a neurotransmitter known as ‘‘serotonin.’’ Experimental evidence suggests that serotonin induces early satiety. Based on this evidence compounds that stimulate serotonin action have been advocated for the treatment of obesity. For example a famous or notorious combination of phentermine phen and fenfluramine fen was found to be extremely effective in suppressing appetite unfortunately it was also associated with adverse effects that led to its withdrawal from the market. Overall it is not unreasonable to foresee that in ten to twenty years physicians should have at their disposal medications that will be able to influence appetite satiety and eating habits significantly. These new pharmacological agents will

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97 Living with Diabetes effectively change both our body weight and our body composition. For the time being however the best approach is to embrace the Draznin Rules. Turning Food into Energy Let us now return for a brief moment to the basal metabolic rate BMR the amount of energy required to support body functionsatrest—whenwesleep The more energy we use to support the work of our hearts lungs brains and the like . . . the less energy will remain in our energy stores. for example or thumb leisurely through the pages of the local newspaper. The more energy we use to support the work of our hearts lungs brains and the like in other words the higher our BMR the less energy will re- main in our energy stores. As always the energy we use for the needs of our resting bodies is derived from food. If food

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98 Living with Diabetes is not consumed either intentionally for example during an overnight fast or during an attempt to lose weight or unintentionally if one is starving as a result of either food deprivation or another disease the energy to provide for the basic functions of the body is mobilized from the energy stores. This energy is initially derived from glycogen carbohydrates stored in the liver and in muscle which runs out fairly quickly and then from fat stored as fat tissue which lasts longer. Now that we know that the energy to support the life of an organism is derived from foodstuffs let us briefly review how that actually happens. How does my slice of pecan pie convert into the energy I spend moving from the sofa to the refrigerator Dr. Hans Krebs a scientist who received a Nobel Prize in 1953 for his discoveries of the major steps in the biochemistry

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Insulin Energy and Weight Regulation 99 of energy production elegantly divided this process into three stages. Thanks to food labels everyone now knows that the items we consume are composed of three major nutrients as we call them ‘‘macronutrients’’: proteins carbohydrates and fats. In the first stage of energy production from food large molecules are broken down into smaller units. Proteins are reduced to amino acids large carbohydrates are converted into simple sugars such as glucose and fats are broken down into glycerol and fatty acids. Even though no energy is generated at this point this is the critical preparatory step as only these simple molecules can be used to generate energy at stages two and three. Certain medications that we use to prevent weight gain or to ameliorate diabetes work specifically at this stage. For example acarbose interferes with the breakdown of complex carbohydrates into simple sugars thereby retarding and diminishing the absorption of carbohydrates into the bloodstream. In the second stage of energy production from food these smaller molecules enter various cells and most of them are

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Insulin Energy and Weight Regulation 100 further reduced or degraded into a very few simple units that enter the mitochondria—the energy-making factories of the cells of our bodies. Although some tissues such as heart tissue prefer using fatty acids to generate energy in most cells of the human organism a healthy competition exists between fatty acids and glucose for the privilege of being burnt for the sake of producing new cellular energy. Stage three is the real factory for production of energy. Remnants of sugars and fats are burnt in the energy- producing furnace to generate energy that is stored in high- energy compounds known as ‘‘adenosine triphosphate’’ abbreviated ATP. The ATP molecules function like a battery supporting the life of each cell in the body.

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101 Living with Diabetes Carbohydrates the most abundant source of calories in the human diet are present in both plant and animal products and they are easily broken down into simple sugars for speedy absorption. Carbohydrates are an excellent source of quick energy with 1 g of carbohydrate providing four calories. Excess carbohydrate is readily stored in the liver and muscles in a form of glycogen that is also easily broken down into single molecules of glucose for quick utilization. Proteins are built from twenty-two amino acids eight of which can only be obtained from food. Because these eight amino acids cannot be produced in our bodies they are termed ‘‘essential.’’ The richest source of protein is meat which in combination with milk cheese and eggs provides all eight essential amino acids. Many plant foods also contain substantial amounts of protein. Although like carbohydrates a gram of protein provides approximately four calories proteins are rarely used to cover energy needs. They are much more suitable as building materials to create new proteins in muscle and everywhere else.

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102 Living with Diabetes Fat is the most significant metabolic fuel we have. One gram of fat provides nine calories twice as many as carbohydrates or proteins. Therefore in terms of acquisition of energy fat is the most efficient source. It is particularly important for tissues that use great quantities of energy in their work. These tissues are skeletal muscle and heart muscle. For absorption dietary fats are broken down into single fatty acids and glycerol. In the bloodstream they travel throughout the body and are either used as a source of energy or deposited in storage in fat tissue. Approximately 85 of the body’s energy is stored as fat. How is this relevant to what and how much we eat How is it related to our ultimate weight Or to our ability to lose weight The answers are complex but they are directly and

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Insulin Energy and Weight Regulation 103 critically relevant to the regulation of body weight. According to the law of conservation of energy if we are to maintain our weight the energy we generate during these three stages must be equal to the energy we ex- pend. If we generate more energy than we expend we gain weight. If we expend more energy than we generate we If we generate more energy than we expend we gain weight. If we expend more energy than we generate we lose weight. lose weight. We also have to eat a well-balanced diet so as to avoid unhealthy competition between the macronutrients. If the diet is not hypocaloric composed of fewer calories than are expended the nutrient that is consumed in excess whether it is fat or carbohydrate will immediately be placed into storage. Despite competition for most body cells it is easiest to use glucose as a source of energy. Glucose is the most readily available source of energy. This simple carbohydrate

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Insulin Energy and Weight Regulation 104 is critical for providing energy to the brain the muscles the liver the kidneys and virtually every organ and every cell in the body. As a source of energy glucose can be utilized immediately to generate energy or placed into storage as glycogen a chain of molecules of glucose kept together by chemical bonds. When we fast or exercise glycogen breaks down releasing individual molecules of glucose into the energy-production pathway. Unlike plants animals cannot produce glucose from fat directly. Practically speaking this means that consumption of a diet with a high fat content cannot raise the blood-sugar levels directly. In contrast to the production of glucose from fat the opposite process—the production of fat from glucose—is very much possible in the animal kingdom. After all bees make fat wax from sugar honey. Piglets grow into large fat pigs and

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105 Living with Diabetes ducklings grow into succulent fat ducks on a carbohydrate- rich diet. This happens because the storage of excess energy in fat is much more efficient than the storage of energy as glycogen carbohydrates . In the human however this concept has been difficult to prove. Numerous studies have shown only minimal conversion of glucose into fat in human beings. However in the Central African country of Cameroon the Guru Walla tribe has an interesting tradition of overfeeding. Guru Walla adolescent boys consume about 7000 calories in carbohydrates daily and they gain twelve kilograms over twenty-six pounds in ten weeks while ingesting only a minimal amount of fat. Case Study: Mr. G. Let us now consider the story of Mr. G. Mr. G. is a forty- twoyear-old accountant who eats a well-balanced diet consuming approximately 3200 calories daily. He does not watch the distribution of fats and carbohydrates in his diet

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106 Living with Diabetes but he looks for ‘‘no cholesterol’’ items in his favorite grocery store. He leads a fairly sedentary lifestyle and his walking is limited to the distance from his car to either his office or a grocery store. His BMI is 29 and his caloric expenditure is approximately 2800 calories per day. He is concerned with a recently accelerated weight gain. Clearly as long as his caloric intake 3200 calories exceeds his caloric expenditure 2800 calories Mr. G. will continue to gain weight. He is said to be in a positive calorie balance þ400 calories and he will not lose weight no matter what the composition of his diet is. At his yearly physical Mr. G. was found to have cholesterol levels of 290 mg/dl. He began a low-fat diet. He is now buying low-fat yogurt and low-fat cream cheese he eats pasta twice a

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Insulin Energy and Weight Regulation 107 day and he snacks on apples and oranges consuming about four fruit servings each day. His caloric intake is now down to 2900 calories. After an initial loss of three pounds his weight had remained stable for four months but over the next six months Mr. G. gained six pounds. His cholesterol came down to 260 mg/dl. With the best of intentions Mr. G. replaced calories derived from fat with calories from carbohydrates. His lifestyle did not change and his diet is still not hypocaloric low-calorie. Even though he burns carbohydrates he consumes so many that in the absence of exercise the carbohydrate excess is directed to storage and conversion to fat.Mr.G.wouldderivegreater benefit from this new diet if he were to start an exercise program to stimulate his mus- Mr. G. would derive greater benefit from this new diet if he were to start an exercise program to stimulate his muscles to burn the excess carbohydrates.

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Insulin Energy and Weight Regulation 108 cles to burn the excess carbohydrates. With Mr. G.’s current lifestyle a high-carbohydrate diet would lead to a greater weight gain and would not help him with his cholesterol. Mr. G. has read about an ‘‘all you can eat’’ high-protein high-fat low-carbohydrate diet. His coworker lost ten pounds in three weeks on this new wonder diet. Mr. G. eagerly jumped onto the bandwagon. He now eats a three- egg omelet and two servings of meat a day as well as a lot of cheese and he drinks a glass of whole milk with each meal. His daily caloric intake is 3000 calories. After an initial loss of seven pounds over the first month he maintained his weight for three months and gained nine pounds over the next nine months. He has frequent morning headaches and he is very tired by the end of the day. His lifestyle has not changed.

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109 Living with Diabetes Because he stopped consuming carbohydrates Mr. G. quickly depleted his carbohydrate storage glycogen and lost a lot of water that was stored along with the glycogen. This explains his initial weight loss. Mr. G.’s diet is still not hypocaloric. With his glycogen stores depleted his liver cannot generate sufficient amounts of glucose after an overnight fast. Because glucose the main energy source for his brain is now scarce his liver makes ketones a chemical product that can be used as a replacement fuel. However ketones when produced in excess can be toxic. With this compensatory ketosis a state of excessive production of ketones Mr. G. began experiencing morning headaches and he is becoming excessively tired by the end of the day. In fact he is so tired that he cannot even think about adding exercise to his daily routine. Mr. G. persists in his mistake of not switching to a hypocaloric diet. Instead he is currently on a ketogenic diet that worsens his fatigue and introduces a new problem morning headaches. Commonsense Conclusions

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110 Living with Diabetes What Mr. G. should be doing is quite obvious. He must begin a well-balanced hypocaloric diet and change his sedentary lifestyle. He should consume a daily diet of approximately 2300 calories with 40–45 carbohydrates 35–40 fat mainly monounsaturated and polyunsaturated and a healthy mix of low-carbohydrate and Mediterranean diets. At the same time he should start a walking program building his tolerance to three Draznin Miles a day. This will assure slow but steady and substantial weight loss an improvement in his lipid profile and most important a lifelong weight-maintenance plan and a healthy lifestyle.

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Chapter Six A Person Does Not Lose Weight by Diet Alone To Kill Diabetes Permanently Click Here r. K. whom we met earlier is sitting in front of me awaiting recommendations. I see in his eyes that in his mind he has already made a commitment to follow my advice. After much trial and error he wants to give my program a good try. But is Mr. K. a candidate for a M

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low-carbohydrate diet Would he lose weight improve his blood-sugar level and lower his blood pressure Would he reverse his insulin resistance Would he reduce his risk of developing heart problems and diabetic complications Would he stick with the Draznin Mile program at home and at work while on business trips and on vacation These were the questions that crossed my mind as I listened to Mr. K.’s complaints carefully examined him and perused his two-inch-thick medical record— all the while sorting out To change a lifelong set of my approach to his problems. I know what he has to do but habits is not a trivial task. I also know that progress will be difficult for him. To change a lifelong set of habits is not a trivial task. 59

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113 Living with Diabetes Mr. K. and I are now teammates. We are looking straight into each other’s eyes. We have established a common goal: to defeat his obesity and diabetes before they defeat him. With his commitment before us I make a counter- commitment to him: I will guide him to success. I will be available to him whenever he needs me and I will use my time and knowledge to lead him to what has now become our common goal. Every single day I see patients like Mr. K. in my office. I learned a long time ago that patients without patience do not do well. The road to success is filled with frustration and setbacks. I can only promise to do my best to guide them through the roadblocks. They may follow my guidance but it is up to them to overcome the setbacks. Frustrated people try to diet again and again and again only to go through the same routine: initial success followed by a bounce-back after a few short months. No wonder so many individuals give up trying to diet. It is not surprising that people jump on every new gimmick on every new diet and on every new pill that purports to help.

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114 Living with Diabetes National statistics do not lie. They clearly show that almost everyone who starts a weight-loss program loses weight. To lose weight initially has never been a problem. The huge problem is that 90 of dieters regain weight within the first year after an initial weight loss For many the yo-yo dieting continues for decades. But I am confident that your efforts will not be in vain if you faithfully embrace the Draznin Rules of lifestyle. The Importance of the Hypocaloric Diet Based on the law of conservation of energy we can state with confidence that if Mr. K. consumes fewer calories than he expends he will lose weight. Plain and simple. No miracles. That is why all diets that restrict food intake work. Physicians and nutritionists call these ‘‘hypocaloric’’ diets. Hypocaloric means

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A Person Does Not Lose Weight by Diet Alone 115 that the diet provides fewer Hypocaloricmeans that the diet calories than are needed to provides fewer calories than are cover daily energy require- needed to cover daily energy ments. While on these diets requirements. patients consume less energy than they expend. They are said to be ‘‘in negative energy balance.’’ In fact these people have to mobilize additional energy from the storage places—that is from fat and from glycogen remember glycogen is the storage form of sugar— to meet their energy needs. Spending more than one has leads to a loss whether in money or in extra pounds of flesh. Hence we invariably lose weight on hypocaloric diets. The easiest analogy to help understand the concept of the negative energy balance is your weekly financial balance. Suppose you receive a weekly salary of 500. Even though you have a savings account in your local bank you are trying to live from check to check with a weekly budget of 500. Generally speaking you spend 500 a week for food

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A Person Does Not Lose Weight by Diet Alone 116 housing car expenses and other miscellaneous items. If one week you have suddenly spent your 500 by Wednesday the only way you can meet your financial obligations on Thursday and Friday is by withdrawing additional funds from your savings account. You have just found yourself in negative balance. You can exist in negative balance until you deplete your savings account. Fat around your waist and hips is your energy saving. If you consume less energy than you spend you will be continuously depleting your fat storage. Unlike the money in the above example which we wish would grow monthly if not daily your goal is to deplete your energy savings and get rid of your fat. So the first step in Mr. K.’s new lifestyle program is quite clear: Mr. K. must be put on a hypocaloric diet. But what exactly does that mean

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117 Living with Diabetes If you consume precisely the same amount of energy as you spend you are said to exist on an ‘‘isocaloric’’ diet. In other words you are in a state of equilibrium as far as energy is concerned. In this state of equilibrium you are not going to lose or gain any weight. With the goal of losing weight what you really wish to know is how much less intake than that of your isocaloric diet you must adopt in order to place yourself in negative caloric balance. The most scientific way to calculate by how much your calorie intake should be restricted is to measure your basal metabolic rate BMR and then go on a diet that allows you 300–500 calories less than your BMR. If we had measured the BMR of Mr. K. we would have learned that it was approximately 2200 calories. After subtracting 400 calories I would recommend that he consume a diet of 1800 calories per day. For him this number of calories would be hypocaloric. For most people a diet containing 1200–1500 calories is sufficiently hypocaloric relative to the BMR and they should lose weight consistently and safely while on such a diet.

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118 Living with Diabetes Some people begin their dieting with a very low–calorie diet a diet containing between 400 and 600 calories daily. This is a drastically reduced caloric intake and one would certainly lose weight like this. However these diets can be dangerous for people with certain medical problems or even for otherwise healthy individuals. One should consult a doctor before starting such a diet but even with a physician’s blessing no one should be on one of these very low–calorie diets for longer than ten to fourteen days. All successful diets are hypocaloric including every popular diet that you can find on the shelf of your favorite bookstore or on the Internet. Whether you are on the Atkins diet the Ornish diet the Zone diet the South Beach diet Draznin’s dietary

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A Person Does Not Lose Weight by Diet Alone 119 principles after reading this book or any other diet you will only lose weight if you consume fewer calories than you expend. Using a computer program known as the Food Processor SQL nutrition and fitness software one can easily calculate the caloric content of the popular diets from the menus they recommend. It turns out that the introductory menu of Dr. Atkins contains 1400 calories per day including 29 g of saturated fat The Zone diet recommends 1340 calories per day and the Sugar Busters diet recommends 1000 calories per day. Absolutely undoubtedly surely and unequivocally one will lose weight on any one of these diets Short-term success is guaranteed. But if all these diets are hypocaloric meaning that you eat less how come some of their advertisements and testimonials tell you that you can eat as much as you want and still lose weight Do they lie Not necessarily. But they certainly don’t tell you all the truth and nothing but the truth. They play tricks with your appetite. For example people who are on Dr. Atkins’ diet and consume only proteins and

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A Person Does Not Lose Weight by Diet Alone 120 fat have livers that will generate a lot of ketone bodies to supply energy to their brains—in order to substitute for the missing glucose usually supplied by carbohydrates. Ketone bodies suppress appetite. But they can also cause headaches reduce your ability to concentrate and make you feel more tired. As a result you will eat less. With a complete lack of carbohydrates those who follow the Atkins diet are no longer providing good-quality energy for their brains. Furthermore a diet completely devoid of carbohydrates can and frequently does cause constipation. Fatigue and nausea may be associated with the ketotic state. Many patients on low-carbohydrate diets experience dizziness and they may have a

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121 Living with Diabetes significant drop in blood pressure when they stand up quickly. A high-protein diet also creates an additional workload for the kidneys and this could precipitate kidney stones and gout. Beyond that a diet of only meat and eggs day after day after day doesn’t taste that great either. How many strips of bacon and fried eggs can you eat Perhaps the biggest problem with the Atkins diet is that we don’t really know what kind of damage it can do to our hearts if we manage to stick with it over the long haul. Dr. Atkins honestly believed that no harm would be done by his diet even if it is consumed for many many years. In fact he argued that in the long run his diet would reduce blood- cholesterol levels. I believe that Dr. Atkins was only partially correct. His diet may result in lower production of very low–density lipoproteins VLDLs which are fats that contain triglycerides and cholesterol. A 50 reduction in

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122 Living with Diabetes . . . Unlimited consumption of saturated fat can be extremely detrimental to the heart and blood vessels even when cholesterol levels are reduced. VLDL production for example will result in an approximately 10 reduction in cholesterol levels. However unlimited consumption of saturated fat can be extremely detrimental to the heart and blood vessels even when cholesterol levels are reduced. Overall until good clinical studies are conducted it would be prudent to avoid the Atkins diet as a long-term solution. Dr. Ornish’s diet is truly hypocaloric. It eliminates fat and many proteins—essentially all food items with high caloric density. Dieters are advised to eat grains and fibers. But two major problems arise with this diet. First it just doesn’t taste good. After a while all these wonderful grains without a

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123 Living with Diabetes trace of fat become tasteless. No matter how you slice it this is not

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A Person Does Not Lose Weight by Diet Alone 124 an appealing palatable diet. At least not to most of us. Consequently it would take an incredible commitment on the part of a patient to adopt the Ornish diet as a long-term solution to his or her needs. The second problem is that if one sticks to this regimen one is almost constantly hungry. Not only is this diet hypocaloric but its high carbohydrate content is constantly stimulating the release of insulin. Insulin lowers blood-glucose levels and increases appetite. People on this diet are always hungry and are always munching on granola and other grains that provide only short-term relief. It is both masochistic and heroic to stay on this diet beyond several weeks. The Zone diet is more balanced than either the Atkins diet or the Ornish diet. But it also must be hypocaloric to be successful. While allowing intake of all three major nutrients— protein fat and carbohydrate—it limits the overall size of your meal the size of your meat and fish no larger than the size of your palm and the amount of carbohydrates. To stay ‘‘in the Zone’’ so to speak and not be hungry you have to consume great quantities of low-caloric fruits and vegetables—in

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A Person Does Not Lose Weight by Diet Alone 125 other words roughage. The Zone diet also has a set of complicated rules that must be followed in order to calculate protein requirements based on several tables and charts. You must also calculate the amount of protein and fat eaten when consuming carbohydrates in order to remain in ‘‘the Zone.’’ Understanding Dietary Composition A study that I conducted at the University of Colorado has revealed another interesting finding about the composition of a given diet and its impact on overall dietary effectiveness and ultimate success. We gave our overweight patients a hypocaloric diet—400 calories a day less than was needed to maintain their energy balance in a neutral position. In other words they

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126 Living with Diabetes had a 400 calorie-a-day deficit compared to what they spent. One half of these patients received a hypocaloric diet low in fat and high in carbohydrate content while the other half received a hypocaloric diet enriched in fat and low in carbohydrate. Because the diet was hypocaloric all patients lost weight over a period of sixteen weeks. However insulin-sensitive patients lost more weight on a high- carbohydrate hypocaloric diet. In contrast insulin-resistant patients lost considerably more weight on a high-fat hypocaloric diet. This suggests that the state of insulin sensitivity governs individuals’ responses not just to diet but also to dietary composition. Lately thisconcept hasbeensupportedbya numberofstudies from other institutions. For example a group of researchers from Children’s Hospital in Boston under the leadership of Dr. David Ludwig demonstrated that a low-carbohydrate diet 40 carbohydrates was more effective in achieving weight loss in individuals with higher levels of insulin—by definition a group of more insulin- resistant subjects.

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127 Living with Diabetes After many years of wrangling and after a meteoric rise and a precipitous fall of the low-carbohydrate fetish the question of which diet is the best is still an open one. Very recently Dr. Michael Dansinger and colleagues at the Tufts- New England Medical Center compared head to head the Atkins Ornish Weight Watchers and Zone diets in 160 participants each randomly assigned to one of these four popular diets. They found that each diet modestly reduced body weight at one year. Not surprisingly the overall dietary compliance was poor but better adherence to the diet resulted in greater weight loss. This was true for all four diets and there was no advantage of one diet over the others. Somewhat different results were published by a group of clinical scientists from Stanford University. This group led by

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A Person Does Not Lose Weight by Diet Alone 128 Dr. Christopher Gardner reported a slight but significantly greater weight loss in overweight and obese women on the Atkins diet than in those on the Zone Ornish or LEARN Lifestyle Exercise Attitude Relationship and Nutrition— another high-carbohydrate diet diet at 12 months of followup. Longer-term studies are still needed to compare the relative efficacy of these diets. In summary the Atkins diet may negatively affect our blood chemistry and hearts while lifelong converts to the Zone and Ornish diets are hard to find. So if all these popular diets result in weight loss how come we as a nation are becoming more and more obese The answer is simple. Nine out of ten dieters regardless of the regimen they choose cannot keep up their dietary efforts for long and certainly not forever. The seventh Draznin Rule is as follows: A person does not lose weight by diet alone. Successful dietary The seventh Draznin Rule is as follows: A

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A Person Does Not Lose Weight by Diet Alone 129 modifications must be accompanied by permanent person does not lose weight by diet alone. changes in lifestyle especially by exercise. Statistically speaking the only dieters who are able to maintain their reduced weight are those who incorporate exercise into their lives. After you have lost weight and shed those unwanted pounds exercise is the key to success in keeping your body from regaining what you had to work so hard to lose. Let me explain why it is so vitally important. Today when the tastiest and the most appealing food items contain high levels of both carbohydrates and fat we overeat without even noticing it. Our energy reservoirs are constantly filled to capacity. The fat we consume is stored inside our bodies as fat under the skin and wrapping around our organs such as the heart liver kidney and so forth.

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130 Living with Diabetes Fat is our long-term reservoir of energy. It takes time to build up fat deposits and unfortunately it takes even longer to get rid of excess. In contrast for its immediate needs the body uses energy stored as glycogen a form of stored carbohydrates. Glycogen is very easily and rapidly made from glucose in the liver and in muscles. This process is called glycogenesis and it is under the tight control of insulin. After a meal complex and not so complex carbohydrates are split into individual molecules of glucose in the gut intestines . These molecules are then absorbed into the bloodstream and trigger the release of insulin. Insulin pushes glucose into cells and tissues and it stimulates the deposition of the excess glucose as glycogen in the liver and muscles the liver picks up glucose without the help of insulin. Thus our old friend insulin helps build up glycogen stores and prevents glycogen breakdown. In contrast between meals or during exercise when the levels of insulin are lowest glycogen is broken down to provide glucose for

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131 Living with Diabetes the brain and other organs. During fasting or exercise the levels of insulin are low and cannot prevent glycogen breakdown into individual molecules of glucose which can now be used as a rapidly accessible energy source by all the organs of the body. Hence glycogen provides energy for the immediate needs of the organism. When glycogen depots that is how scientists refer to glycogen storage are depleted but the body still needs energy then and only then do fat cells begin to release the fat needed to provide the required energy. The glycogen stores can be depleted in two ways. One way is to eat a low-calorie lowcarbohydrate diet so that insulin will not be able to convert glucose into glycogen. Another way to diminish our glycogen stores is to exercise. Exercise requires energy and stimulates the breakdown of glycogen so as to liberate the molecule of glucose

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A Person Does Not Lose Weight by Diet Alone 132 that can be now utilized in the energy-production pipeline. In the absence of glycogen and with a low-carbohydrate diet the body will start using fat as the energy source thereby helping maintain the reduced weight. What is even more important to understand is the opposite process. When the glycogen depots are completely filled and yet one continues to consume carbohydrates where do these carbohydrates go With energy production not in demand and the energy stores filled to capacity the glucose excess is converted to fat. Knowing how difficult it is to stay on a hypocaloric lowcarbohydrate diet it is not surprising to realize that without exercise we will almost undoubtedly fail any dietary regimen and regain all those dreaded pounds. Study after study has clearly shown that only people who accepted exercise as a new way of life were able to keep their weight down years after shedding the extra pounds. Diet Plus Exercise

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A Person Does Not Lose Weight by Diet Alone 133 For quite a long time patients with diabetes and their physicians have realized that exercise in addition to helping us lose weight lowers blood-sugar levels. This observation was subsequently translated into valuable practical advice which was given to many patients with diabetes: exercise. At the same time scientists working in the fields of weight regulation and diabetes wished to know the mechanism of the effect of exercise on blood-sugar levels. Scientists are very curious people. They wish not only to know that action A produces effect B but also to learn as much as possible about this How exercise helps maintain reduced weight and decrease blood-sugar levels is not a trivial question.

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134 Living with Diabetes process and to understand what happens at every step along the way from A to B. How exercise helps maintain reduced weight and decrease blood-sugar levels is not a trivial question. Better understanding of the cellular and biochemical events accompanying exercise might and probably will lead to better treatment options in the future. Some of the very first experiments with exercise revealed that uptake of glucose by muscle cells can be activated by muscle contractions which is the essence of exercise independently of insulin. Even in insulin-resistant patients—those who did not respond well to insulin— exercise effectively stimulated the entry of glucose into cells thereby reducing the levels of sugar in the blood. So exercise was found to be able to circumvent the inactivity of insulin and promote the entrance of glucose from the bloodstream into various organs and tissues. What proved to be especially important for patients with diabetes was that in response to exercise training their bodies became much more sensitive to insulin. In other words insulin began working much more efficiently in those insulin-resistant

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135 Living with Diabetes patients who became involved in a long-term exercise program. Clearly exercised muscle demands more energy than does muscle at rest. Energy for cellular utilization is produced mainly from glucose either from new glucose molecules that enter the cell or from glucose stored in the cell and liberated from glycogen a compound that stores glucose. If one exercises long enough one begins depleting glycogen stores in order to supply glucose for sufficient production of energy. Freeing up space in the glycogen store is important in at least two ways. First with a decline in supplies of intracellular glucose cells begin using fatty acids as an alternative fuel to produce energy. Fatty acids are derived from fat that breaks down to liberate this alternative fuel. Second when some time after

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A Person Does Not Lose Weight by Diet Alone 136 exercise a person consumes carbohydrates newly absorbed glucose can be deposited in now depleted stores and will not be turned away to be converted into fat. From a practical point of view exercise is a superb adjunct to both a weight-treatment program and a diabetes- treatment plan. In and of itself without an appropriate diet exercise . . . exercise is a superb adjunct to may not be very successful and both a weight-treatment program certainly is not expected to be curative. But along with diet and a diabetes-treatment plan. and medications as needed it helps in keeping weight down and controlling diabetes. The opposite is also true. Without a meaningful exercise program diet alone usually fails and the treatment of diabetes is not very successful. Finally please remember that the three Draznin Miles a day will make all the difference

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Chapter Seven A Tale of Two Brothers To Kill Diabetes Permanently Click Here o you remember how many times your parents told you that your brother behaved better studied harder and kept his room much cleaner than you did They repeatedly pointed out that he even liked homemade soup when all you wanted was a slice of cheese pizza. By the time D

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you enrolled in high school you knew pretty well that your brother Tom was very different from you. He was and still is a very smart nerd. He could spend an entire evening thumbing through the Encyclopedia Britannica or solving mind-twisters from Games magazine. You however with your bountiful energy and awfully short attention span would rather have played ball ridden your bike or played video games. Every time your parents compared you to your brother you screamed back ‘‘I’m not Tom I’m not my brother I’m Johnny’’ The truth of the matter is that you were absolutely correct. You were and you still are very different from your brother. And both of you are strikingly different from your parents distinctly different from your sisters and a world apart from your cousins. In fact no one would ever contemplate comparing you with your cousin Harry and your sister would never 72

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A Tale of Two Brothers 139 be confused with your cousin Sarah. Even though we share many genes with and may physically resemble other members of our immediate or extended families we all are individuals. We have our Even though we share many genes with and may physically resemble other members of our immediate or extended families we all are individuals. own individual characters mind-sets culinary habits and athletic abilities. Why then do dietitians and doctors and authors of popular diet books offer one and the same prescription for all of us Let us now suppose that you and I develop the same disease hypertension high blood pressure. It turns out that you and I live in the same neighborhood and go to the same doctor a friendly and knowledgeable family physician. When you and I visit our doctor we do not expect to be treated in exactly the same way. The doctor is likely to prescribe different medications for us or at least different doses of the same medication. We realize that even though we have the same diagnosis the disease is acting upon two

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A Tale of Two Brothers 140 distinct individuals—you and me— causing somewhat different problems and requiring individualized therapy. Exactly the same principle applies to recommendations with regard to diet and exercise. They simply cannot and should not be the same for everyone. The key is to select the most appropriate regimen for a given patient. Not everyone has to avoid egg yolk and not everyone must be on chromium and manganese. The amounts of carbohydrate in the diet must be adjusted to the degree of physical activity of the individual person whereas the amounts of protein must be adjusted according to the ability of the kidneys to handle the protein load.

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141 Living with Diabetes Although the goal of a physician who treats many patients is uniform—to achieve the best possible control of blood pressure and sugar levels and to design the best program for weight maintenance—the means to reach this goal can be as distinct as night and day. The approach and the means ought to be routinely individualized by paying close attention to the patient’s state of mind physical abilities tastes habits and work and leisure schedules as well as the presence of other medical conditions. Two Brothers Two Treatment Plans Here is a fairly straightforward example of how different Tom is from his brother Johnny. Tom is a forty-six-year- old selfemployed plumber who gets his job assignments from a general contractor. He is usually out his door at 6:00 AM after drinking a glass of orange juice and on a construction site forty-five minutes later. His first meal is about 10:00 AM and lunch is at about 1:00 or 1:30 PM. Both meals are usually eaten at the nearest fast-food restaurant. Tom tries to be home before 6:00

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142 Living with Diabetes PM and he eats dinner with his family at 6:30 or 7:00 PM. Tom is five feet nine inches tall and weighs 190 lb. His body mass index BMI is 28. His weight has been stable for the past five years. Two years ago he developed diabetes which is treated with two pills a day. His fasting blood-sugar levels are still moderately elevated running at about 150– 160 mg/dl except for weekends when they go up to 200 mg/dl. His cholesterol and triglycerides are also moderately increased. His brother Johnny is a forty-nine-year-old clerk with the state motor vehicle department. He eats breakfast at home at 7:00 AM lunch in the cafeteria at noon and dinner at home at about 6:30 PM. At home Johnny is as sedentary as his brother mainly watching TV and thumbing through his favorite

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A Tale of Two Brothers 143 magazines. However unlike Tom who toils on construction sites five days a week Johnny is sedentary at work as well spending eight hours at his desk and occasionally taking a leisurely stroll to the men’s room. Johnny is five feet ten inches tall and weighs 215 lb. His BMI is 31. He has had diabetes for five years and despite therapy his blood-sugar levels constantly hover near and above 200 mg/dl. His lipids are significantly elevated his blood pressure is mildly elevated. Discussion Both Tom and Johnny are overweight and have diabetes. Both brothers have elevated lipids and higher than normal blood pressure. Johnny’s BMI is in the obesity range most likely because he leads a much more sedentary life than his younger brother does. Tom is very active during work hours and his sugar levels are lower because of the vigorous manual labor he is engaged in five days each week. Neither brother pays much attention to his diet. More severe obesity

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A Tale of Two Brothers 144 and higher sugar levels are probably responsible for higher lipids and blood pressure in Johnny. What shall we recommend to Tom and Johnny If we look solely at the diagnoses the two brothers appear to have the same disease. One may even assume that they should be treated in an identical manner. This assumption would be incorrect and far from the reality of the situation. Tom should start by bringing lunch from home instead of eating on the go gobbling up hamburgers and pizzas. Because he is so active his daily caloric intake should probably stay at about 3000 calories. I would encourage him to do three Draznin Miles on Saturdays and Sundays and two Draznin Miles twice a week on weekdays. With just a little more structured exercise and better nutrition Tom should do

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145 Living with Diabetes very well. Obviously adjustments will have to be made if Tom’s blood sugar and lipids do not drop to normal levels despite the changes in diet and exercise. He may need to start taking lipid-lowering medications if his cholesterol remains higher than is optimal for patients with diabetes. In addition Tom should definitely stop drinking beer on weekends. Johnny however has a much longer way to go to reduce his weight and to improve his diabetes blood pressure and lipid levels. His diet should be reduced to approximately 2 200– 2500 calories consisting of no more than 45 carbohydrate mainly as vegetables fruit and fiber. He must also begin an exerciseprogrambuildingtothreeDrazninMilesfivedaysawe ek as described earlier in this book. He might also benefit from meditation exercises which could help lower his blood pressure. Johnny should start antihypertensive and lipid- lowering therapies right away. Just like his younger brother he should forget about drinking beer or other alcoholic beverages.

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146 Living with Diabetes As you can see despite . . . despite fairly similar conditions fairlysimilarconditionsTom Tom and Johnny should get and Johnny should get inindividualized therapies even dividualized therapies even before medications are considered. before medications are considered. Their diets may be extremely different and they should be tailored to their individual tastes and food preferences. Getting Individualized Care from Your Doctor After thirty years of practicing medicine I have not yet seen two identical patients in my examining room even though some of my patients have been identical twins I assure you that the concept of designing treatment based on the individual and his

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A Tale of Two Brothers 147 or her life circumstances is not some sort of ‘‘holistic medicine’’ substituted for traditional medicine. Physicians incorporate individual patient adjustments into their practices every single day. It is necessary to consider important elements of a patient’s life while formulating a thorough assessment and a treatment plan. The advent of managed care however has increased the pressure to provide low-cost health care and this prevents some primary care physicians from spending any extra time with their patients to discuss these topics. Doctors are pressured to see more patients in the course of their eight- to ten-hour workdays and they are not reimbursed for discussing modes of exercise and dietary habits with their patients. A meaningful discussion of lifestyle modifications cannot be accomplished in five or ten or even thirty minutes. The American Diabetes Association ADA a premier health- care organization in this country issues a yearly compilation of its clinical recommendations designed to serve as guidelines for both patients and their physicians as far as standards of therapy are concerned. These recommendations

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A Tale of Two Brothers 148 indicate that at the time of the initial visit of a patient with diabetes to his or her doctor the physician must take a comprehensive medical history perform a meticulous physical examination collect the details of previous treatment programs including nutrition exercise and self- management education and obtain information on eating habits nutritional status and weight history. At the end of the visit according to the ADA guidelines a physician shall formulate both short- and long-term goals outline medical and nutritional therapies discuss lifestyle changes as needed offer an exercise prescription and review self- management issues. If your doctor is doing all this you are in good hands. Stay with him or her. Unfortunately this may not happen too often

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149 Living with Diabetes . . . to receive the highest quality of care one must often see a specialist—an endocrinologist or a diabetologist. in the primary care setting. Even the best primary care doctors frequently do not have time to accomplish all these tasks. Therefore to receive the highest quality of care one must often see a specialist—an endocrinologist or a diabetologist. Recently intriguing and revealing statistics from the Third National Health and Nutrition Examination Survey NHANES III were published by Dr. Maureen Harris of the National Institutes of Health. A national sample of 733 adults with type 2 diabetes demonstrated that 95 of these patients had primary care providers 88 had two or more physician visits annually and 91 had health-care insurance. Moreover very appropriately 88 of these patients had been screened for hypertension and 84 for lipid abnormalities. So far so good right Everything about this group of people indicated a high quality of care. However the outcomes of the care were much less satisfactory. Forty-five percent of these adults were obese

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150 Living with Diabetes with BMI levels of over 30 58 had poor control of their diabetes with HbA1c glycosylated hemoglobin—this is a measure of glucose control where values over 6.5 are considered abnormal over 7 60 of those with high blood pressure and abnormal lipids were not controlled to accepted levels and 22 of the patients still smoked cigarettes. To me these statistics are very telling. They speak loudly to the fact that primary care physicians do not have adequate time to devote to patient education and to the problems of their patients’ lifestyles. Excellent and dedicated physicians in primary care practices are at a terrible disadvantage when it comes to the amount of time they can spend with their patients because the current

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A Tale of Two Brothers 151 system of health-care delivery is less than optimal. That is why in the current health-care environment your family doctor may not be able to direct you properly through the maze of medicinal and dietary choices and other lifestyle- related decisions. Simply put he or she has no time to do it. You however as a patient or as a consumer are hungry for this type of information and guidance. That is why you purchased this book and numerous other diet and health guides. You are swimming all alone in this sea of information searching for a magic lifeboat that will rescue you from the deadly current of your negative lifestyle. Two Patients One BMI Before we end this chapter I would like to acquaint you with two of my patients Mr. T. and Ms. E. Both were significantly overweight and they had identical BMI levels of 38. But that was where the similarities ended. Mr. T. was a professor of English literature at the local college a well- educated man forty-five years of age with high blood pressure and gout and with a long list of psychological

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A Tale of Two Brothers 152 problems related to a lack of self-confidence and self- esteem. In contrast Ms. E. was a twenty-one-year-old single mother of three with no other health problems juggling a full-time job in a grocery store with evening classes in a community college while living under extreme socioeconomic pressure. The fact that these two patients had identical BMI values had very little to do with the choice of therapy for them. The genetic bases for body size metabolism feeding habits and physical activity—the mechanisms that had caused their obesity their psychological profiles their social and economic environment and their health histories—dictate the selection of therapy.

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153 Living with Diabetes We are still a long way from complete understanding of how these factors either individually or in concert influence weight maintenance and energy balance in a given patient. Sooner or later you too will discover that there is no magic cure-all. There is only knowledge and your own willpower.

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Chapter Eight Treatment of Obesity eight loss is really all about weight maintenance. Granted it is difficult to shed extra pounds but most people can do it over a short period of time. What proves to be exceptionally challenging as I’ve said already earlier in this book is keeping the new reduced weight and not bouncing back to the prediet existence. W

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How do we treat obesity How are we going to advise Mr. K. who is so eager to combat his weight problem What do we say to thousands of others with similar problems The very first step in considering a multitude of therapeutic options is to modify our attitudes toward obesity see Table 8.1. By ‘‘our attitudes’’ I mean the attitudes both of physicians and of patients. Society must accept obesity as a chronic health condition and not just as a manifestation of weakness or sloth. His- torically obese individuals have been considered unmotivated ugly and somewhat lazy people who are unable to control their voracious appetites. Society must accept obesity as a chronic health condition and not just as a manifestation of weakness or sloth. 81

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156 Living with Diabetes Table 8.1 Treatment of Obesity Step 1 Modify your attitude toward obesity Step 2 Set realistic goals Step 3 Assess your mental readiness Step 4 Find a knowledgeable and willing physician Step 5 The Draznin Mile Step 6 The Draznin Calorie Step 7 Modify your eating habits Ironically this perception is strongly supported by the numerous diet books that create the impression that losing weight is an easy simple and trivial task. These books offer recipes for losing weight. Their authors imply that the key to losing weight is widely known—it is in your hands right in front of your very eyes jumping out at you from the pages of their best-selling books. The implication is that obese people those gargantuan monsters simply lack either

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157 Living with Diabetes interest in losing weight or the willpower to become slim and handsome. Even though the recipe for losing weight is readily available to them these thankless and thoughtless creatures pass up this wonderful opportunity and simply do not wish to become masters of their own fate. ‘‘I have lost eighty pounds’’ says a smiling thirty-five- yearold woman from a full-page ad. ‘‘You can do it too’’ ‘‘I’ve lost thirty pounds in thirty days’’ screams another testimonial. ‘‘And I’m never hungry’’ Not surprisingly everyone who believes these statements looks at the obese man or woman with astonishment and with questions. If losing weight is so simple how come we can’t do it Easier Said than Done The truth of the matter is that it is extremely difficult to lose weight. Obese people and those who treat them know this.

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Treatment of Obesity 158 Losing weight and keeping it off isn’t simple at all it is profoundly complex and exceedingly difficult. It should not and cannot be trivialized. The treatment of obesity is one of the most frustrating experiences in all of medicine. In many cases obesity cannot and will not be cured. At the present state of clinical and scientific knowledge we have no cure for obesity just as we cannot cure diabetes or hypertension—we can only treat them. We can improve control and certainly ameliorate the health problems associated with obesity but cure it I seriously doubt it. Not yet anyway. I submit to you that when I hear my patients say ‘‘Doctor but I cannot exercise’’ or ‘‘Doctor I just cannot be on a diet’’ I do not dismiss these statements lightly. Not all of us can play the violin. Not all of us can draw pretty pictures. Not all of us can pitch a baseball without even mentioning speed and strike zone. Why then do we expect that all of us should be able to enroll in an exercise class Conceivably because of their genetic makeup certain individuals ‘‘select’’ to avoid physical activities. Surely

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Treatment of Obesity 159 they can be forced to exercise but of their own volition they won’t. Even if they are fully aware of all the potential benefits of exercise some people just cannot do it. I would safely bet my nickel that most of us would not continue with violin lessons either. One could argue that this parallel is inappropriate because playing the violin requires talent while exercising requires only perseverance. Not true. No matter what type of activity you enroll either yourself or your children in chances are that the majority of the enrollees will drop out within a year be it a cooking class or a music lesson or a foreign language club. We tend to select activities that we enjoy and we are therefore more likely to continue with them. For some of us exercise or a new healthier diet could never become an enjoyable part

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160 Living with Diabetes of our lives. It will always be a chore always a struggle always a pain. This is precisely the reason for the incredibly high attrition rate from the various diet and exercise programs. In fact in one nationwide study when overweight individuals were offered enrollment in a weight- reduction program and were given free medications the attrition rate at the end of a year was a whopping 30 Thirty percent of people dropped out despite free medications and specialized attention to their health care. Truth is stranger than fiction. Realistic Expectations Recalling that the ideal body weight is the weight associated with the least adverse health consequences we should aspire to achieve this modest goal and not to win the swimsuit competition at the local beach . . . the second step in our treatment club. So the second step in of obesity is to set realistic goals. our treatment of obesity is to set realistic goals. Most

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161 Living with Diabetes experts agree that losing 5–15 of initial body weight is both realistic and achievable other experts in obesity assert that losing just 5–10 of the initial body weight and keeping it at that level for one full year is a commendable goal. Weight loss of this magnitude also automatically improves many of the health problems associated with being overweight. For instance if Ms. Q. who tipped the scale at 200 lb could lose twenty pounds and maintain herself at 180 lb for a year she and her doctor should be congratulated. At that point the new and slimmer Ms. Q. and her physician may set new goals. However if she expects to shed seventy pounds and go down from 200 to 130 lb—and keep that weight off indefinitely— she will most likely fail never achieving these unrealistic expectations. We should realize that quick fixes just like get-rich-

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Treatment of Obesity 162 quick schemes have never worked and never will. Both patients and their physicians should be well prepared for a long haul with lifestyle modifications being the key to their success. The third step in the treatment of obesity please note that we haven’t used any medica- tions or special diets yet is to assess whether a patient is mentally and emotionally ready to initiate serious therapy. This state of readiness for behavioral change is crucial in an over- The third step in the treatment of obesity . . . is to assess whether a patient is mentally and emotionally ready to initiate serious therapy. weight person because if a patient is not ready to make a major commitment to weight reduction none of the programs will work. The weight-loss process requires full concentration and sustained effort so it should not be initiated when other major problems such as family or

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Treatment of Obesity 163 financial matters are dominant in a person’s life. This person will simply fail to devote the necessary effort and commitment to his or her weight problems while encumbered with other important concerns. Not surprisingly instead of a positive outcome the patient will face yet another defeat with the ensuing emotional consequences. Once a patient makes a comguide the patient toward reasonable goals. This is not a trivial task in the era of healthmaintenance organizations HMOs mitment to change his or her lifestyle toward defeating obesity the fourth step is to find a physician who has time to deal with these problems and to . . . the fourth step is to find a physician who has time to deal with these problems and to guide the patient toward reasonable goals.

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164 Living with Diabetes While people whose body mass index BMI levels are under 30 can probably benefit from self-directed diet and exercise programs those with a BMI between 30 and 40 must seek professional guidance as it is highly unlikely that they will succeed on their own. My experience is that nine out of ten patients in this latter weight category will fail to achieve even minimal success without appropriate guidance. There are too many pounds to be lost and too many skills to be learned and applied correctly. Patients with BMI levels over 40 will most likely benefit from bariatric surgery a procedure that surgically minimizes the size of the stomach and the amount of food that can be consumed and absorbed. Self-guided therapy the weight-loss program that patients can pursue on their own basically consists of careful attention to diet eating habits and exercise. Number one numero uno the key element the cornerstone of all and every weight-reduction diet is that the diet must be hypocaloric. If this condition is not met one might as well kiss all other efforts goodbye. There will be no miracle of weight loss. No one can circumvent overcome or alter

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165 Living with Diabetes nature’s law of conservation of energy. If a diet is not hypocaloric there will be no success and no weight loss. So if you see or hear an advertisement for a pill that will help you lose weight while eating anything and everything you wish don’t believe it even for a second. If you swallow the bait and decide to waste your money to buy this ‘‘wonder pill’’ you will be taken for a ride. Recently while I was in line to pay for my groceries I read an article in one of the popular magazines that attracted my attention. Written by a dietitian the article informed the reader that if one maintains a diet of 1400–1600 calories no food is forbidden. One can eat anything and still lose weight as long as one stays within this range of total caloric intake.

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Treatment of Obesity 166 Theoretically this statement might be true but in a practical sense it is grossly misleading. You simply cannot eat an 800calorie piece of rich birthday cake in one sitting and maintain a 1400-calorie diet. You would either eat almost nothing else for the rest of the day and remain hungry until the next or overeat at the next meal which is exactly what is going to happen. The next several steps in treating obesity are all bundled together. They ought to be entertained simultaneously. Each day one must start eating approximately 500–1000 calories per day less than one expends during that day. Most obese men will lose about a pound a week by consuming around 1800 calories a day. Most women would lose the same on a 1400calorie diet. Losing a pound a week doesn’t sound like much but multiplying this modest loss by the number of successful weeks one can expect to lose twenty-six pounds in six months or fifty-two pounds in a year This is a very substantial weight loss. At the same time we should realize that it is very difficult to keep to a nutritionally sound diet on less than 1200 calories per day. The diet of 1200 calories

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Treatment of Obesity 167 or less must be fortified with vitamins and minerals as described below. Along with a hypocaloric diet you must embark on an exercise routine and build up to three Draznin Miles a day as described earlier in the book. The three Draznin Miles must become an integral part of life like brushing your teeth or washing your hands. That won’t happen in a day or in a week or even in a month. But it might happen in a year. That is where true commitment to lifestyle change comes into play. Another key component of a successful transition to a ‘‘leaner life’’ is the modification of eating habits. In addition to commitment this one requires education and knowledge of nutrition. Given a choice most people in the Western world will select food with 40 fat up to 20 sugar and variable

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168 Living with Diabetes amounts of high–glycemic index food items the concept of the ‘‘glycemic index’’ is discussed in more detail in Chapter 11. You need to know the reason for changing your longstanding eating habits how to change them and what will replace the habits that You will have to change when where and how you eat. You have to be honest with yourself and carefully write down what you eat and when you eat it. Then you will identify what you actually wish to change and can begin working on it one thing at a time. are no longer healthy. You will have to change when where and how you eat. You have to be honest with yourself and carefully write down what you eat and when you eat it. Then you will

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169 Living with Diabetes identify what you actu- ally wish to change and can begin working on it one thing at a time. For example if you identify that you eat while driving or watching TV this can be stopped first before you introduce other modifications. Every week you should have a written plan for your modification goals. Recently a telling statement appeared in a review of the influence of dietary composition on energy intake and body weight written by doctors at Tufts University in Boston: ‘‘Although data from comprehensive long-term studies are lacking published investigations suggest that the previous focus on lowering dietary fat as a means for promoting negative energy balance has led to an underestimation of the potential role of dietary composition in promoting reductions in energy intake and weight loss.’’ In my view this convoluted admission of the failure of past recommendations is an understatement. Clearly replacement of dietary fat with great quantities of carbohydrates has played a major role in the epidemics of obesity we encounter today.

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Treatment of Obesity 170 One way to understand whether eating behavior is important to the prevalence of obesity is to understand human eating behavior. Most commonly three aspects of eating behavior have been studied most. These are restraint disinhibition and hunger. Dietary restraint is defined as a tendency and ability to conscientiously restrict food intake. This is exactly what dieters do: They restrict their food intake either to lose weight or to prevent weight gain. This restraint is voluntary and it relates either to quantity of food or to the type of food one wishes to restrict. Disinhibition is the tendency to overeat palatable food items either simply in the presence of these items or as a result of other disinhibiting stimuli most commonly emotional distress. Finally hunger is a powerful signal for food intake that can easily override voluntary restraint. Notwithstanding the importance of the interplay between hunger and restraint higher disinhibition has been strongly associated with greater weight gain. Because the presence of our favorite dishes before our eyes is one of the most powerful disinhibiting stimuli it is clearly one of the most

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Treatment of Obesity 171 important factors in our eating behavior. Everyone is guilty of this—I’m not sure I can restrain myself when a scoop of chocolate ice cream is placed in front of my eyes. The best way to deal with disinhibition is to avoid buying the high– caloric density items we have previously enjoyed so much. Depression or emotional imbalance can contribute significantly to overeating. Many people lose control of their eating patterns when they are struggling with problems at work or at home or when they slip into depression. The Energy Value of Foods At the same time you should learn about the energy values of different food items. You should understand how to evaluate

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172 Living with Diabetes nutrition labels so as to determine the caloric content of the food you consume. Food labels are not as simple as they appear at first glance. They give you the amounts of nutrients in grams in one serving the serving size and those nutrients’ percentage of a daily 2000-calorie diet. For example the label of an item you are considering buying tells you that a single serving contains 12 g of fat and that that represents 18 of the recommended daily value. You must understand that if you were to eat a 2 000- calorie diet you could consume 65 g of fat a day. If you ate this particular item with its 12 g of fat for breakfast you would have the rest of the day at your disposal to eat the remaining 53 g of allowed fat 65 g – 12 g ¼ 53 g. Sixty- five grams of fat will provide you with 585 calories 65 g 9 calories/g ¼ 585 calories which will represent 30 of the 2000-calorie diet. Even if you memorize grams and percentages for a 2000-calorie diet it would be difficult to calculate precisely what you have to eat. And then if you are placed on a 1500-calorie diet all the calculations would have to be done anew.

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173 Living with Diabetes Here is a practical example of how you actually do it. Ms. J. was placed on a 1500-calorie diet with the following composition of nutrients: carbohydrates 45 fat 35 protein 20 . This meant that she should receive 675 calories from carbohydrates 1500 calories 45 ¼ 675 calories 525 calories from fat 1500 calories 35¼ 525 calories and 300 calories from proteins 1500 calories 20¼ 300 calories. Now we have to recall that 1 g of fat yields nine calories whereas 1 g of carbohydrates and proteins each yields four calories. Upon dividing 675 calories by 4 Ms. J. will discover that she can eat 168 g of carbohydrates daily. In a similar manner she will calculate that she can eat 58 g of fat and 75 g of protein.

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Treatment of Obesity 174 Armed with this information Ms. J. decides to eat for breakfast one serving of food that contains 25 g of carbohydrates 15 g of fat and 20 g of protein. She knows that this meal breakfast will supply her with 315 calories. She now also knows that during the rest of the day she may still eat 143 g of carbohydrates 43 g of fat and 55 g of protein. She can now plan very carefully what she will eat for lunch dinner and snacks. But most of all she realizes that she can follow this diet only if she plans it in advance. Is that difficult You tell me. I think it is. At least it is by no means easy. Can one do it Can you do it The answer is yes one can and you can. You don’t have to be a rocket scientist but this is where your commitment and perseverance really count. You will have to write down everything that enters your mouth. You will have to calculate the amounts of macronutrients and the number of calories in every serving you put on your plate. You will have to do that at least initially in order to learn what to eat and how much to eat. This learning curve is absolutely critical for your ultimate success.

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Treatment of Obesity 175 If you were one of my patients I would meet with you weekly or even more often until your dietary regimen became crystal clear to you. We would go over your dietary recall a list of the items you eat and your calculations to ensure you were eating the desired number of calories composed of the desired amounts of carbohydrates proteins and fats. Since you are reading this book and so are probably not one of my patients can you count on the help of a primary care physician I certainly hope you can but I wouldn’t bet on that. There is nothing wrong with your primary care physicians. I am convinced they are excellent doctors. Unfortunately as I mentioned before primary care physicians simply do not have time in their busy daily schedules to devote even ten minutes to these

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176 Living with Diabetes calculations. They refer their patients to dietitians who know nutrition and who are excellent in their field but they do not know your specific disease. The vicious cycle begins again— patients are left to fend for themselves perusing the diet books and self-improvement magazines. Medications and Other Chemicals What about diet pills Do we have a magic bullet that can kill our appetites melt our fat and boost our energy expenditure That would be ideal wouldn’t it The reality however is that such a pill is a long way away. Today we have nothing like that. Not yet. Such a miracle treatment is still a dream for many patients and for scores of drug companies that would love to offer such a panacea to a ‘‘hungry’’ public. Currently only two drugs Meridia sibutramine and Xenical orlistat are approved by the Food and Drug Administration FDA as long-term therCurrently only two drugs . . . apeutic agents for obesity. Sibu-

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177 Living with Diabetes are approved by the Food and Drug Administration FDA as long-term therapeutic agents for obesity. tramine works by blocking the absorption by nerve cells of certain chemicals in the brain which has been shown to result in inhibition of food intake in experimental an- imals and in humans. In one well- designed study patients who took sibutramine lost 8 of their initial weight compared with a loss of only 1–2 in patients who received a placebo a sugar pill with no active ingredient. Most important the weight loss was still present after twelve months of therapy. Side effects of sibutramine are usually mild and disappear rapidly after the drug is discontinued. The most common side effects include dry mouth headache constipation and poor

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Treatment of Obesity 178 sleep. In many patients however physicians have also observed increased heart rate and a mild increase in blood pressure. For these reasons blood pressure and pulse must be carefully monitored in patients taking sibutramine. Not surprisingly as a result sibutramine should not be given to patients with poorly controlled hypertension irregular heartbeat or certain other heart conditions. It should also be used with great caution in patients with glaucoma in patients with migraine headaches and in those being treated for depression. Another way to treat obesity with medications is to attempt to block absorption of fats from the gastrointestinal tract. The idea is that one can eat fatty food and at the same time take a pill that will prevent absorption of these fats from the gut intestines into the bloodstream. The fat will stay in the gut and will eventually slide down through the loops of the intestine and be evacuated. Xenical orlistat is such a drug. It works by blocking absorption of fat from the gut by as much as 30 . In clinical studies orlistat produced an average loss of 10 of the initial weight and it was very

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Treatment of Obesity 179 effective in weight-maintenance programs for up to two years with continued use of the medication. One caveat is that patients taking orlistat should limit the amount of fat in their diets to less than 30. Otherwise large amounts of unabsorbed fat will cause oily stools. With so much fat the stool will slide down the intestine reaching your undergarment faster than you can reach the nearest toilet These patients will have an urge to relieve themselves very frequently this is called ‘‘fecal urgency’’ and to their great displeasure they will not always be able to hold it in ‘‘fecal incontinence’’. This is a very unpleasant embarrassing and annoying side effect indeed Limiting the fat content of the diet will help prevent this side effect.

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180 Living with Diabetes You probably remember that several years ago ‘‘fen- phen’’ was a promising combination of two medications fenfluramine and phentermine that suppressed appetite. This medical regimen became extremely popular among both physicians and diet-conscious patients. The drugs however were found to cause infrequent but severe side effects such as heart valve problems and were pulled off the market. Lately a great deal of interest has been shown in the potential effectiveness of herbal medications—in particular a ‘‘natural fen-phen’’ or ‘‘herbal fen-phen’’ has become exceptionally popular. The term ‘‘natural’’ or ‘‘herbal’’ fen- phen refers to a combination of Saint-John’s-wort and ma huang an ephedra herb. When used separately the former is generally praised for its antidepressant properties whereas the latter is a mild to moderate stimulant. Together they are reported to be helpful in curbing appetite. No scientific evidence however exists to support this claim. Incidentally herbal remedies are not without hazard. Lately ephedra has been under scrutiny for possibly contributing to the death of

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181 Living with Diabetes several prominent athletes who exercised strenuously in the heat of summer while taking this substance. For those of you who are eager to use prescription and over- For those of you who are eager to use prescription and over-thecounter medications to fight your weight problems it’s important to keep in mind that the long-term safety of these medications is in most cases completely unknown. the-counter medications to fight your weight problems it’s important to keep in mind that the long-term safety of these medications is in most cases completely unknown. Furthermore how long does a medication even the most benign one need to be taken Will three months suffice A couple

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Treatment of Obesity 182 of years Perhaps twenty years Will the long-term use of these medications improve or impair health We simply do not know. Finally one should realize that patients with a BMI greater than 40 who have failed to lose weight with various behavioral and pharmacological approaches should consider surgery as a viable option in treating their obesity. The number of weightreducing surgeries they are known as ‘‘bariatric surgeries’’ is increasing rapidly by up to 40 each year as more and more people consider this option. In 2004 120000 bariatric surgeries were performed in the United States while in 2006 the number of bariatric surgeries exceeded 200000. Today two types of surgery are usually performed in obese individuals: gastric restriction and gastric bypass. Gastric restriction is a procedure that creates a small pouch in the stomach that basically restricts the amount of food the stomach can receive thereby limiting one’s caloric intake. Smaller amounts of digested food continue to move along the normal route of the remainder of the gastrointestinal

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Treatment of Obesity 183 tract. In the gastric bypass operation the major part of the stomach and the small intestine are surgically bypassed thus also reducing absorption of nutrients. Both procedures regarded realistically result in approximately 40 weight loss with good long-term maintenance. Weight loss in these patients is associated with significant improvement in diabetes hypertension breathing disorders and mobility. The latest analysis of published outcomes suggested that a special type of gastric bypass called ‘‘Roux-en-Y’’ reversed diabetes in 84 of obese diabetic patients who underwent the procedure. Surgery however is not without complications and one should select a medical center and physician specializing in this type of surgery. It goes without

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184 Living with Diabetes saying that surgical candidates must be fully informed of potential complications. Many centers require that patients go through a thorough psychiatric evaluation to estimate their strength of commitment and ability to cope. Medicating Prediabetes As the old concept of prediabetes reemerged in clinical medicine and the scientific literature many physicians and their patients began pondering an important question: Should prediabetes be treated with medications in order to prevent its transition to full-blown diabetes Lifestyle changes prevent the development of diabetes in 50–70 of patients with prediabetes. Will medications do the same Will they be equally effective And if so what medication should we use Will there be side effects of these medications in the long run Because many patients with prediabetes are either unwilling or for whatever reason unable to modify their lifestyle the search for a ‘‘magic pill’’ continues in the laboratories of almost all pharmaceutical companies. It is

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185 Living with Diabetes easier for a busy doctor to prescribe a pill than to get involved in a long tedious and frequently frustrating effort to modify a patient’s lifestyle. Unfortunately today only one drug available on the market offers some reasonable benefit in preventing diabetes. This medication is metformin and it is also used to treat diabetes. Metformin is currently given to overweight children and adolescents as well as to prediabetic adults. The success of metformin is variable but is somewhere around 35 . Other medications such as Avandia rosiglitazone or Actos pioglitazone may be equally effective but their long-term safety is not yet established and their potential side effects do not allow doctors to use them widely. Intuitively based on common sense and today’s scientific information I would

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Treatment of Obesity 186 recommend these medications only as a short-term measure designed to help my patients change their eating habits and their lifestyles. While waiting for a breakthrough in the search for such medications lifestyle changes and the Draznin Plan remain the best approach to the treatment of prediabetes.

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Chapter Nine What Shall I Do When I Stop Losing Weight Despite My Best Efforts to Keep My Diet and Exercise To Kill Diabetes Permanently Click Here s. S. is a tall and overweight woman of 38 years of age. She is five feet eleven inches tall and weighs 237 lb. She has been gaining weight steadily from the time of her first pregnancy ten years ago. At some point in the not M

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so distant past she weighed 267lb but with a strict diet and exercise regimen she lost thirty pounds over approximately eight months. Initially her weight loss was rapid and visible improving her mood and motivating her to stay with her new healthy diet and exercise program. She lost twelve pounds in the first month eight pounds during the second one five pounds in the third three pounds in the fourth and one pound during the fifth and the sixth months each but nothing since. She remains exceptionally strict with her diet and walks almost two hours every day. She has been doing everything she was supposed to do. Not surprisingly her stalled progress became a source of frustration and disappointment. WhathappenedWhydidMs.S.graduallystoplosingweight while still adhering to the same regimen that was so successful initially These questions are very common as is Ms. S.’s predicament among thousands of dieters trying to lose weight. Unfortunately

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98

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What Shall I Do When I Stop Losing Weight 190 in the great majority of people frustration overwhelms their ability to cope and against their best judgment they slip off the wagon and return to overeating and underexercising thus regaining the weight they worked so hard to lose. A slow pace of weight loss or an apparent lack of weight loss after initial success and the resultant inability of patients to stay with a given program can be similarly frustrating to a physician. Some ‘‘experts’’ would nonchalantly say ‘‘Eat less and exercise more—that’s all there is to it.’’ Easier said than done. In fact at this point when a person has already lost a substantial amount of weight it is almost impossible to . . . in the long run the goal of losingweight must become the goal of maintainingthe new and reduced weight. do. As a result this cavalier advice sounds like a mockery a mental torture of sorts. This is precisely why in the long run the goal of losing weight

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What Shall I Do When I Stop Losing Weight 191 must become the goal of maintaining the new and reduced weight. From a scientist’s point of view it would be both interesting and imperative to understand why and how this new equilibrium develops. Why after the initial weight loss do we reach a plateau that seems unresponsive to previously successful measures If we understand the mechanism we will be much better equipped to design appropriate therapy to come up with a plan to reinstill both hope and enthusiasm. For now however there is only one way to deal with this problem constructively. It takes time resolve and a lot of patience. Keeping Goals Reasonable I tell my patients ‘‘Let’s lose 5–10 of the initial body weight and keep the new and reduced weight for at least six months to a year. This initial weight loss is likely to occur within the first six months. Let’s not worry for now and not expect to lose a

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100 Living with Diabetes quarter or a third of your weight. Let’s lose 5–10 of your weight and keep this loss for six months to a year and consider this a success. The maintenance phase or period of time during which we want to keep the reduced weight will then last for an additional six to twelve months. If we are successful in maintaining the initial weight loss over the next six to twelve months we will then devise a new strategy for an additional 5 –10 weight reduction for the next six to twelve months.’’ With these expectations—that appear modest upon first glance—people are likely to build the necessary confidence patience and stamina to acquire a new lifestyle. This is the Draznin Plan at work. Why it is so difficult to maintain reduced weight is not known but many researchers in the field of obesity and nutrition are trying to answer this important question. One theory was put forth by two obesity researchers from the University of Colorado Holly Wyatt and James Hill. They postulated that our bodies have genetically defined requirements for energy expenditure. In other words the

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body of a given individual strives to spend a certain number of calories to maintain the work of all organs in the body both at rest BMR or basal metabolic rate and in activity AT or activity thermogenesis. As we already know from Chapter 3 the largest share of daily energy expenditure approximately 50–65 is spent on BMR to support the function of brain muscle bones fat heart liver and all other organs in a body. The larger the body is the greater amount of energy is expended to maintain its functions. Drs. Wyatt and Hill named this difference between the two levels of energy expenditure pre- and post- weight loss the ‘‘energy gap.’’ They concluded that filling the energy gap with exercise would prevent weight gain and allow the patient to maintain a reduced weight.

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What Shall I Do When I Stop Losing Weight 194 Let us consider an example. Mr. X. weighs 200 lb and his energy expenditure is 2500 kcal a day. He is a sedentary man who is almost never physically active. After a year of dieting he lost twenty pounds and now weighs 180 lb. Because his body mass is now smaller than it was by twenty pounds his energy expenditure also went down—let’s say to 2300 kcal. However according to Wyatt and Hill’s hypothesis his body now packaged in a smaller frame retains its genetically predetermined need to spend 2500 kcal. He can comply with this demand in one of two ways. He can either exercise to burn expend an extra 200 kcal and then his total daily energy expenditure will meet the required 2500 kcal 2300 kcal plus 200 kcal burned by exercise. Alternatively he can regain weight back to 200 lb and then his body would burn the required 2500 kcal without exercising. The price for this second option is heavy—a regain of the initially lost weight. If Wyatt and Hill are correct and if the ‘‘desire’’ of the body to spend energy is genetically determined and remains relatively constant during a lifetime then we have no other

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What Shall I Do When I Stop Losing Weight 195 option but to be sufficiently physically active to fill this ‘‘gap’’ with exercise for the rest of our lives in order to maintain a reduced weight. New studies and excess weight. For now however a reduction in caloric intake combined with three Draznin Miles each day remains the best recipe for a healthy lifestyle change. experiments with cohorts of overweight people are needed to determine whether filling the ‘‘energy gap’’ with exercise is the only option for patients struggling with For now . . . a reduction in caloric intake combined with three Draznin Miles each day remains the best recipe for a healthy lifestyle change.

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102 Living with Diabetes Changes in Cognitive Function Obesity and diabetes are chronic illnesses. Very frequently chronic illnesses including obesity and diabetes are accompanied by slight changes in cognitive function—so slight that they may be imperceptible to patients and their families. This is particularly true for older people those over the tender age of 65 and certain elements of cognitive impairment have been observed in 15–50 of older adults with chronic illness. ‘‘Cognitive function’’ is a very broad term that encompasses all kinds of thinking abilities including information processing the application of knowledge to practical situations and changing preferences and desires. In many instances the changes in cognitive function that accompany chronic illness are so subtle that overall mental abilities to work and carry out activities of daily living do not appear to be altered at all. However imperceptible changes in learning may be serious enough to interfere with

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or even prevent a person’s ability to adapt to a new lifestyle. As a result even if we health professionals put our best efforts into patient education and patients do their best to learn what they are supposed to do this newly acquired knowledge often fails to change patients’ behavior. Just as outstanding knowledge of music theory does not equal the ability to play a musical instrument learning everything about diet exercise and diabetes does not equal the ability to effectively combat obesity and diabetes. The process of acquisition of knowledge is known as ‘‘declarative learning.’’ But new knowledge acquired in the process of declarative learning does not directly affect habits. A child can easily learn that one must brush his or her teeth twice a day but this does not mean the child is going to do it. The acquisition of knowledge is not the same as the acquisition of a habit. A different type of learning ‘‘procedural learning’’ or ‘‘habit-

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What Shall I Do When I Stop Losing Weight 198 forming learning’’ is desperately needed to ensure that new knowledge leads to a new lifestyle. This frequently observed dissociation between acquisition of knowledge about obesity and diabetes and the development of new habits to fight these chronic diseases with a healthy lifestyle may be the result of a mild impairment of cognitive function in these patients. Another important change in cognitive function frequently seen in patients with chronic illnesses is related to what is known in the world of psychology as ‘‘executive cognitive function.’’ The abilities to plan anticipate consequences of action initiate purposeful changes and activities monitor self-action and detect errors all fall into the category of executive cognitive function. So a person with impaired executive functioning may have difficulties with initiating purposeful changes such as starting a new lifestyle inhibiting irrelevant behavior the habits of the old lifestyle and monitoring the accuracy of his or her performance. These are all critical elements for

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What Shall I Do When I Stop Losing Weight 199 selfmanagement of diabetes and for maintaining a healthy lifestyle. Finally behavior change requires substantial effort but effort is difficult. As we all know it is much easier to do what is habitual. Changing rooted habits in order to defeat obesity and diabetes is exceptionally difficult. Yet building new habits is absolutely critical for the successful alteration of a lifestyle.

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Chapter Ten The Draznin Calorie: A Better Way to Diet To Kill Diabetes Permanently Click Here ow that we are fully armed with the concept of the Draznin Mile knowing and accepting that one must log three Draznin Miles a day we ought to face the second side of the energy-balance equation: the consumption side. What is the maximum caloric intake we N

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can allow ourselves and still lose weight What would be a sensible dietary limit that assures weight loss initially and weight maintenance afterward And most important how can we practically implement such a program over a long period of time both at home and while visiting friends or eating out The answer to all these important questions is the Draznin Calorie. A calorie is scientifically defined as the amount of energy needed to raise the temperature of 1 g of water from 158C to 168C or from 598F to 618F. One kilocalorie or 1 kcal equals 1000 calories. The caloric content of food is presented in kilocalories so the calories we count in our dietary ration are really thousands of those little units of energy needed to heat a gram of water by one degree. For example 500 calories consumed or expended are 500000 calories or 500 kcal in ‘‘true scientific count.’’ 104

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The Draznin Calorie 202 A Calorie by Any Other Name... The concept of the Draznin Calorie is quite different from that of both the chemical calorie and the dietary calorie but it is as simple as the concept of the Draznin Mile. Though this concept is not difficult to understand it can be incredibly difficult to follow. Every time the body has an energy deficit that is when we expend more energy than we consume the brain is bombarded with signals of hunger prompting the body to increase energy intake—in other words to eat more. The mind and body work in tandem to maintain the energy balance and if possible to store extra energy for a rainy day. Therefore the critical question for every dieter is how to comply with a hypocaloric diet or even with a balanced diet in order to lose weight or to prevent weight gain. The first step of my approach is quite obvious. We must eliminate from the diet all items with high caloric density. These are the items that contain a lot of calories per small amount of food—per bite or per gulp if you wish. These food items contain large quantities of fat or sugar such as

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The Draznin Calorie 203 deep-fried food or nondiet soft drinks and juices. These should be eliminated at once. After eliminating high-fat and high-carbohydrate items from the diet the remaining food items can be classified as containing between one and six Draznin Calories per serving. How Simply look at food labels. They always tell you how many calories per serving the food item contains. Armed with this information designate any food item that contains fewer than 100 calories per serving as containing one Draznin Calorie. For example one egg one . . . designate any food item that contains fewer than 100 calories per serving as containing one Draznin Calorie.

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204 Living with Diabetes small to medium-sized apple one slice of whole wheat toast and one glass of skim milk each contain one Draznin Calorie regardless of the actual calories present. Sound familiar Remember my exercise plan: When you walk for twenty minutes you cover one Draznin Mile regardless of the true distance traveled. All food items containing between 101 and 200 calories per serving are said to equal two Draznin Calories. Examples include three ounces of poultry or lean meat or fish one dinner roll or one cup of lean meat–based soup. Table 10.1 demonstrates the Draznin-Calorie equivalent of the caloric content of certain foods. The eighteen different food items used most commonly by patients adhering to my program are listed in Table 10.2. The key element of my program is to eat no more than six Draznin Calories per meal and no more than eighteen Draznin Calories per day. Because one Draznin Calorie equals or is less than 100 calories consuming six Draznin Calories per meal means that one consumes no more than 600 calories. Consuming eighteen Draznin Calories a day

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205 Living with Diabetes assures that the caloric intake for that day will stay below 1800 calories. Together with walking three Draznin Miles a day this is an excellent and Table 10.1 Caloric Content of Food and Draznin Calorie Equivalent Caloric Content Draznin Calories Up to 100 calories/serving 1 101–200 calories/serving 2 201–300 calories/serving 3 301–400 calories/serving 4 401–500 calories/serving 5 501–600 calories/serving 6

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The Draznin Calorie 206 Table 10.2 Common Food Items and Draznin Calorie Equivalents Food Item Draznin Calories 1 egg 1 2 breakfast turkey links 1 1 slice whole wheat or rye toast 1 1 glass skim milk 1 3 oz lean meat/poultry/fish 1 1 cup vegetables 1 1 cup fruit 1 1 dinner roll 2 1 tsp salad dressing or oil 1 1 cup vegetable soup 1 1 cup meat-based soup 2 1 cup creamy soup 3 Appetizer restaurant 3 Salad restaurant 2 Entre´e-size salad restaurant 4 Entre´e without garnish 3 Entre´e with garnish 5 Dessert 6

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The Draznin Calorie 207 efficient way to lose weight. By the way if you ate only four Draznin Calories at breakfast you cannot add the remaining two to your lunch or dinner. Remember that each meal must be no larger than six Draznin Calories. If you eat less good for you Table 10.3 provides an example of a breakfast containing fewer than six Draznin Calories. The new lean lifestyle is based on spending energy while doing at least three Draznin Miles a day and consuming no more than eighteen Draznin Calories no more than 1800 calories. Many of my patients carry a small pocket calendar– sized card with the caloric content of allowable food items in Draznin Calories. Simply by checking off the number of Draznin Calories per meal they can easily stay within eighteen

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208 Living with Diabetes Table 10.3 Sample Draznin Breakfast Sample Breakfast Item Draznin Calories 1 egg 1 2 slices toast 2 1 turkey link 1 1 glass skim milk 1 Total Draznin Calories 5 Draznin Calories a day and successfully continue with the program. Restaurant items are typically more caloric than homemade food. Usually an appetizer in a restaurant contains 300–400 calories equal to four Draznin Calories. Restaurant items are typically more caloric than homemade food. A large entre´e-sized salad easily contains 400–500 calories and this should be counted as four Draznin Calories. A meat poultry or fish entre´e usually larger than

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209 Living with Diabetes three ounces prepared with oils and sauces and served with garnish equals five Draznin Calories. Desserts cover the entire meal—six Draznin Calories. Based on this count when eating out we have several choices see Table 10.4. Dinner at home may contain a plate of salad one Draznin Calorie with a teaspoon of no-fat dressing one Draznin Calorie a dinner roll two Draznin Calories and six ounces of grilled chicken two Draznin Calories for a total of six Draznin Calories. One can skip the roll and instead have either a larger portion of meat or a side dish of vegetables still staying within the allowable six Draznin Calories. With this concept of the Draznin Calorie the only information you need from the food label is the size of a serving and the number of calories per serving. If the number of calories per

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The Draznin Calorie 210 Table 10.4 Sample Dinner Menus Menus Draznin Calories Choice 1 Vegetable soup 1 Dinner salad 2 Entre´e without garnish 3 Total Draznin Calories Choice 2 6 Vegetable soup 1 Appetizer 3 1 dinner roll 2 Total Draznin Calories Choice 3 6 Meat-based soup 2 Large entre´e salad 4 Total Draznin Calories Choice 4 6

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The Draznin Calorie 211 Dessert 6 Total Draznin Calories Choice 5 Any combination that does not exceed 6 Draznin Calories 6 serving is under 100 simply count it as one Draznin Calorie. If you decide to eat two servings of this food item you will consume two Draznin Calories. Make a note on your chart and make sure you eat no more than six Draznin Calories per meal and no more than eighteen Draznin Calories per day. I recommend that you keep an accurate record in Draznin Calories of what you eat at each meal do this for three to four

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212 Living with Diabetes months. During this time you will develop a habit of eating foods with lower caloric density and in smaller portions. Coupled with a walk of three Draznin Miles a day you will have developed and will have learned to maintain a healthy lifestyle a slimmer body and a happier spirit. Having been so adamant about an individualized approach to my patients’ problems throughout this book I would like to lead you to my practical advice that can serve as the background for your own lifestyle changes. You or better yet you and your doctor or nutritionist will be able to modify it adjusting it to your taste work and eating schedules family situation and other health problems you might have. The diet might appear somewhat stringent but it isn’t. There is a great variety of vegetables and grilled fish and meat to satisfy every hue of every taste. Finally only two requirements stay constant if one wishes to lose weight: 1 one must consume less energy than one expends and 2 three Draznin Miles must complement one’s dietary efforts. Now here it comes—my practical advice.

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Chapter Eleven Practical Advice hat about alcohol What about eating out What foods should you buy and how should you prepare meals What about having a dinner at a friend’s house Do you have to take extra vitamins and/or nutritional supplements Are there or will there be any effects on your prescription and over-the-counter medications All these are important questions. You must know the answers. Fortunately the answers are simple and reasonable and the advice is easy to follow. W

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Portion Size Throughout this book I continuously emphasize the importance of a hypocaloric diet as the cornerstone of any lifestylechanging regimen. As we’ve already seen one way to consume fewer calories is to select food items that are lower in caloric content. Another and in practical terms perhaps even more important way is to minimize portion size. Avoid eating three large meals a day. In fact avoid eating large portions period. If you eat prepackaged food pay careful attention to a serving size—don’t Avoid eating three large meals a day. In fact avoid eating large portions period. 111

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215 Living with Diabetes eat two servings always be happy with one. Make your dinner the last meal of the day—do not snack after dinner. Make sure there is always a twelve-hour interval between the last bite of your dinner and the first bite of your breakfast. If you finish your dinner at 9:00 PM do not eat your breakfast until 9:00 AM. This is a much needed break for your digestion system and a wonderful way to support your hypocaloric diet. Added Sugars The term ‘‘sugar’’ is used to designate both monosaccharides sugars composed of a single molecule and disaccharides sugars composed of two molecules. The monosaccharides are glucose galactose and fructose. The disaccharides include sucrose lactose and maltose. Monosaccharides and disaccharides are also known as ‘‘simple sugars’’ or ‘‘simple carbohydrates’’ as opposed to ‘‘complex carbohydrates’’ which consist of many simple saccharide molecules. Many commonly used sweeteners such as corn syrup contain trisaccharides or even longer

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216 Living with Diabetes molecules of saccharides. Complex carbohydrates must be broken down in the digestive tract before they are absorbed into the bloodstream. Dietary Guidelines for Americans published jointly by the U.S. Department of Agriculture and the Department of Health and Human Services offers a distinction between ‘‘added sugars’’ and the carbohydrates that naturally exist in food. However the body cannot make this distinction and treats all sugars either added or naturally occurring in the same way. But it is important to understand the term ‘‘added sugars’’ and the impact these sugars have on nutrition. Added sugars are defined as sugars that are eaten separately or ‘‘added’’ as an ingredient to processed or prepared food items such as soft drinks ice cream cakes and pies. Added sugars include white

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Practical Advice 217 and brown sugars maple syrup corn syrup honey molasses and fructose sweeteners to name a few. Consumption of added sugars in the United States has increased steadily from 27 teaspoons per person per day in 1970 to 32 teaspoons per person per day at the present time an increase of 23. Nine specific food items lead the way in added sugars in the American diet: soft drinks 33 fruit drinks 10 candy 5 cakes 5 ice cream 4 ready-to-eat cereals 4 sugar and honey 4 cookies and brownies 4 and syrups and toppings 4. Soft drinks are the clear winner. Added sugars must be completely eliminated from the diet of anyone who wishes to lose weight. Glycemic Index In 1981 a group of investigators led by Dr. David Jenkins proposed the use of the glycemic index GI of individual food items in designing an appropriate diet to treat diabetes. The idea was to classify carbohydrate-containing foods numerically assuming that this might be helpful in treating

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Practical Advice 218 patients with type 1 diabetes. The concept is fairly simple: Each carbohydrate-containing food item causes a rise in bloodsugar levels and the magnitude of this rise relative to the rise elicited by a pure glucose is the GI of this particular food item. Initial studies by Dr. Jenkins compared changes in blood- sugar levels caused by 50-g portions of various The higher the rise in blood-sugar levels after eating a particular carbohydrate the higher the GI of that carbohydrate. carbohydrates with those caused by 50 g of glucose.The higher the rise in blood-sugar levels after eating a particular carbohydrate the higher the GI of that carbohydrate.

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219 Living with Diabetes Later a 50-g portion of white bread was used as the standard instead of glucose. After hundreds of food items were tested generally in healthy volunteers it was determined that refined grain products and potatoes have high GI values causing high elevations in the blood sugar of these volunteers. Legumes and unprocessed grains have moderate GI values and starchy fruits and vegetables have low values. Since Dr. Jenkins and his group developed the GI in 1981 over 100 scientific studies have been conducted to examine the application of the GI to obesity diabetes and even cardiovascular disease. Many popular nutrition books advocate diets based on items with a low GI. This advice is intuitively correct. If one eats food that causes the least elevations in blood-sugar levels one would have a lower carbohydrate load and one should be better able to control one’s diabetes. This idea was later endorsed by the Food and Agriculture Organization of the United Nations. But as you probably guessed the typical Western diet still contains high

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220 Living with Diabetes concentrations of carbohydrates because it is based on potatoes breads and low-fat cereals. Even though the diet based on food items with low GI values makes sense the concept is not as simple as it first appears and not everyone agrees about its usefulness. First the GI was determined for each carbohydrate-containing food item—for example rice potato and spaghetti. Most of us however eat mixed meals—not just rice or just potato or just spaghetti. We eat chips and fish meat and potatoes peanut butter and jelly pork and beans and so forth. Most of our meals contain multiple food items. Just look at our soups and gumbos to see how many ingredients are in one plate The GI of the mixed meal has never been determined. The second problem with relying on the GI for dieting purposes is that 90 of GIs have been determined in experi-

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Practical Advice 221 ments with a small number of healthy young volunteers— people who may digest absorb and respond to food items differently from people of middle age who have certain health problems. In fact many older individuals and patients with diabetes digest and absorb food much more slowly than do younger and healthier people. Remember that each of us has a unique way of handling food—you are not your brother Tommy Third the GI of a food item is influenced profoundly by its type by its processing and by its preparation. For example the GI values of different types of rice vary by almost 100 Similar differences have been found for different types of pasta apples and many other foods. Methods of food processing including grinding pressing and rolling affect the GI dramatically. So does the application of heat and moisture as well as cooling and time of processing. All these steps can damage the outer layers of grains and the chemical composition of starches thereby affecting significantly the GI of these foods.

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Practical Advice 222 Finally the way a food is cooked also modifies its GI. The amount of heat used the amount of water or sauce the cooking time—all are important factors in modifying the GI of food items. In general the more we heat moisturize grind or press a starch-containing item the higher the GI of this item is. The reason is that warmer moister and more finely ground food items are more easily digested and rapidly absorbed. Attempting to design a low-GI diet one could easily drown in the long list of GIs published in the 2002 ‘‘International Table of Glycemic Indices’’ in the American Journal of Clinical Nutrition. The list contains nearly 1300 data entries A better much more practical solution is to limit carbohydrates in your diet as outlined in my recommendations. If you want to lose weight don’t complicate your life by trying to identify low-GI

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223 Living with Diabetes food items. Instead eliminate from your diet the main offenders: potatoes pasta and all sweet and baked goods. Enjoy your carbohydrates in fruits and vegetables but avoid bananas grapes and corn. Dietary Fat We consume two types of fat: cholesterol and fatty acids. The same cholesterol and fatty acids are also produced naturally in the body but consumption of increased amounts of fat can greatly influence the overall concentrations of fat in the blood and in the bodily stores. Cholesterol is absorbed from the gastrointestinal tract with the help of bile which simply functions as a detergent to dissolve cholesterol. After being absorbed cholesterol moves quickly into the liver. A large proportion of it is then released back into the gastrointestinal tract. Because of this efficient recycling system it is very difficult to increase the levels of cholesterol in the blood by eating additional cholesterol. As a rule people who have elevated cholesterol

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224 Living with Diabetes levels have a naturally elevated production of cholesterol in their bodies that they inherited from their parents. Other fats are broken down in the gut intestines into single fatty acids. Not all fatty acids are created equal. They actually come in three varieties: saturated monounsaturated and polyunsaturated. Saturated means that every bond of every carbon atom in the fatty acid is connected with a different chemical group. When a single carbon atom of the fatty acid contains an extra available bond the fatty acid is said to be unsaturated. When more than one unsaturated carbon atom is present in the molecule the fatty acid is polyunsaturated. Saturated fatty acids appear to be associated with heart and blood vessel disease. Unsaturated fatty acids especially

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Practical Advice 225 monounsaturated ones appear to be protective against cardiovascular disease. Saturated fatty acids known as ‘‘the bad fat’’ even though it has never been established in human beings whether saturated fat is really ‘‘bad’’ are Saturated fatty acids appear to be associated with heart and blood vessel disease. Unsaturated fatty acids especially monounsaturated ones appear to be protective against cardiovascular disease. present in meat eggs palm oil and coconut oil. Polyunsaturated fatty acids are found in cold-water fish soybeans nuts and canola oil. Monounsaturated fatty acids are contained in olive oil canola oil avocados and nuts. The so-called Mediterranean diet is famous for its beneficial effect on the heart and its high content of monounsaturated fatty acids. Practically speaking to eat healthfully you should eat more fish than red meat and more olives avocados and olive oil than butter and eggs. Do not use palm or coconut oil. Make sure proteins are included in

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Practical Advice 226 every meal or snack. Remember fat and proteins frequently come together as in eggs fish and nuts. Alcohol First off what do we do with alcohol To drink or not to drink For many of us alcoholic beverages have become a part of life if not a daily routine then a social one. To have a beer a glass of wine or a cocktail is an integral part of social interactions whether with our friends relatives or colleagues or even alone. But if your commitment to losing weight is genuine and serious—if you really truly want to shed pounds—do not consume alcohol. Each and every gram of alcohol contains seven calories that will add to your caloric intake. More important most alcoholic beverages contain a lot of carbohydrates

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227 Living with Diabetes especially beer sweet wines and wine coolers. Beer and wine coolers are deadly to your diet. Furthermore alcoholic beverages increase your appetite. Within minutes after ingestion alcohol reduces blood-sugar levels and triggers a hunger signal to your brain. With food in front of you you will inevitably eat more after having a drink or two than you would have with just a glass of seltzer. In patients with diabetes alcohol may actually raise blood-sugar levels worsening their control of their diabetes. Because it is so vital to your success I wish to repeat my advice. If you are serious about your commitment to weight reduction or to a weight-maintenance program avoid alcoholic drinks by all means. Having said this I realize that on occasion you may find yourself in a situation where you simply cannot refuse an invitation to imbibe. If you are in such a predicament and if you find it hard to refuse a drink I can offer you two options. The first is simply to ask for one glass of dry nonsweet wine preferably a red one and to drink no more. Dry table wines contain fewer calories and carbohydrates and less alcohol

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228 Living with Diabetes than do other drinks. Your second option is to ask for a drink that you truly dislike and just touch it with your lips once or twice during the evening. You will save face and no one will refill your glass As always with drinking one should be cognizant of the amount of alcohol consumed. For example 3 oz of dry table wine contain sixty-eight calories whereas a 12-oz can of beer contains 151 calories. But if you drink 12 oz of dry table wine you will consume 272 calories 68 calories 4 ¼ 272 calories. Similarly 1.5 oz of hard liquor contains 107 calories. Please do not drink 10 oz of hard liquor Aside from your having consumed 740 calories your evening may not end well.

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Practical Advice 229 Eating Out When you dine out follow Draznin rules eight and nine. The eighth Draznin Rule is as follows: If you are overweight and are trying to lose weight never cally all the items on the menu in ever go to a restaurant that serves Asian food. The food there might be excellent but if you have a problem with your weight and/or have diabetes stay away. Practi- The eighth Draznin Rule is as follows: If you are overweight and are trying to lose weight never ever go to a restaurant that serves Asian food. these restaurants contain sugar and a lot of it Not good for a weight-reduction diet The ninth Draznin Rule is as follows: While dining out order only

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Practical Advice 230 grilled or broiled meat or fish— and never order anything that is deep-fried pan-fried or covered with sauces. If you are serious about losing weight never order pasta potatoes or rice but only The ninth Draznin Rule is as follows: While dining out order only grilled or broiled meat or fish—and never order anything that is deep-fried pan-fried or covered with sauces. green and red vegetables. If your entre´e comes with either potato or rice eat as little as you possibly can and never more than half of your serving. Whenever possible order an appetizer or a salad and split an entre´e with your companion. When it comes to dessert fresh fruit is your best option. However if you have not eaten any carbohydrate at all choose the least caloric dessert and split it with your dining partner. In the restaurant please talk to your waiter. Ask how large the portion is and whether you can share your entre´e if it is

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Practical Advice 231 too big. Find out how the food is prepared—broiled fried steamed or saute´ed. Can sauce or dressing be served on the side Will the chef substitute side dishes Don’t be shy— some

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232 Living with Diabetes waiters love these questions. In their minds the longer the preorder discussion the greater the tip at the end of the meal. For you the answers can be critical. For example let us say tonight you fancy clams. Two ounces of steamed clams contain sixty calories and less than a gram of fat. In contrast the same 2 oz of clams breaded and deep-fried contain 250 calories and 13 g of fat. Which one should you order While reading the menu go straight to fish dishes. If there is nothing there that you fancy jump to poultry dishes as an option B. Finally always ask your waiter not to bring complimentary bread. You waited four or five hours for your dinner you can wait twenty more minutes without bread until your appetizer shows up. Now what do you do if you are invited to someone’s house for dinner If it is a good friend call the person and share your dietary philosophy. Tell your friends that you can only eat grilled food and that you are trying to limit both fat and carbohydrate intake. Explain carefully what you mean and what food you will eat with pleasure and without restrictions. Most people will be very supportive.

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233 Living with Diabetes If on the other hand you do not feel as though you can call and discuss your situation with your host have a snack at home about an hour before dinner so you will not be hungry at the table. When you are not hungry you are better able to control both your appetite and your choice of foods. Vitamins and Supplements Vitamins are absolutely essential for many biochemical reactions within various cells. They help numerous enzymes carry out their appropriate functions. Deficiencies in vitamins readily impair these important functions resulting in malfunctioning of different bodily systems. In extreme cases vitamin deficiency

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Practical Advice 234 can cause severe and even fatal disease. In a similar manner frequently certain biochemical reactions in various cells require the presence of very specific minerals such as magnesium chromium calcium and others. Mineral deficiency can also cause significant impairment in bodily functions. We obtain most vitamins and minerals from the foods we eat. Generally speaking a normal diet of 2000 calories or more which includes meat dairy products fruits and vegetables contains sufficient vitamins and minerals and rarely if ever requires supplementation. In contrast however diets containing 1200 calories or less do not supply adequate amounts of vitamins and minerals and these should definitely be supplemented. Similarly diets that selectively exclude certain food items such as vegetarian diets or diets without fruits or vegetables must be supplemented with vitamins and minerals. Make sure you discuss your needs for vitamins and minerals with your doctor. My practical ad-

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Practical Advice 235 vice is that you take vitamin and mineral supplements particularly iron and folate if your diet contains Make sure you discuss your needs for vitamins and minerals with your doctor. fewer than 1500 calories. If you are a vegetarian you definitely need vitamins B2 and B12 as well as calcium iron and zinc. If you are over sixty-five you may need calcium selenium and folate. In any event you must have an informative conversation with your physician about vitamin and mineral supplements. Choose a multivitamin preparation that provides no more than 100 of the daily value ‘‘ DV’’ is what is shown on the label for all the vitamins and minerals included. You certainly do not want any of the side effects of excessive intake of some of these compounds. Only buy supplements that have the U.S.

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236 Living with Diabetes Pharmacopeia USP symbol of quality on their label. Remember that most vitamins are better absorbed with food. However calcium and iron may decrease the absorption both of each other and of other nutrients. They should be taken separately. Finally do not forget antioxidants. Most natural antioxidants are present in dark green and dark orange/red fruits and vegetables. The medicinal value of antioxidant vitamins such as beta-carotene and vitamins C and E has not been scientifically confirmed. Prescription and Over-the-Counter Medications Diets themselves particularly successful ones on which the dieter is losing weight may have an impact on the effectiveness of some medications and so may certain vitamins and minerals. Also medications can alter the absorption and function of particular vitamins and minerals. Interactions can go either way and your medications may suddenly become either more effective or less effective. In both cases adjustments have to be made. That is why you

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237 Living with Diabetes must discuss this issue with your doctor as soon as you begin your dietary efforts. Cooking and Eating at Home You can substantially reduce the number of calories you consume by changing your cooking habits and without sacrificing the taste of your favorite dishes or at least sacrificing very little. The number-one rule is to buy proper ingredients as described here. To begin with the lower the caloric density of the items you buy the fewer calories will end up on your plate and eventually in your stomach. The second rule is to always grill broil steam or poach your food—never fry it. Here are a few other tips that should help you change the way you cook:

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Practical Advice 238 Always trim all the fat from meat and remove the skin from poultry. Always substitute low-fat or nonfat versions of the items in the cooking recipes. Serve food from the kitchen and never bring serving plates to the table. Going for seconds should not be made easy. Do not ever watch TV or read while eating. Focus your full attention on the amount of food you are consuming. Eat slowly. In fact eat as slowly as you can. Do not take anything into your mouth until the previous mouthful of food is completely chewed and swallowed. Store food out of sight. Set aside time to prepare fresh vegetables in bulk and store them until you use them. Do not skip a meal particularly on a day when you are going to a social function. If you are hungry you will most definitely overeat.

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Practical Advice 239 Brush your teeth after each meal. The taste of the toothpaste should replace the taste of food. Finish your last meal of the day at least three hours before you go to bed. Grocery Shopping Here is another critical element of my practical advice: Learn how to select your food in the grocery store.The tenth Draznin Rule is as follows: Never ever buy any food item that contains more than 6 g of sugar per serving. The tenth Draznin Rule is as follows: Never ever buy any food item that contains more than 6 g of sugar per serving.

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240 Living with Diabetes There is only one exception to this rule and it is milk. Milk is the only allowable fluid that has calories and the only allowable product that contains more than 10 g of sugar actually 11 g per serving in fat-free milk. The most appropriate food choices should contain no more than 6 g of sugar and the best choices should have fewer than 3 g of sugar. Items with lower sugar content are there on the shelves you just have to look for them. You must become a ‘‘smart shopper’’ committed to the Draznin Plan. Let us examine for example four Hormel ready-to-eat dinners: Meat Loaf with Tomato Sauce 6 g of saturated fat and 7 g of sugar Grilled Chicken Breast with Teriyaki Sauce 1 g of saturated fat and 30 g of sugar Beef Tips with Gravy 2.5 g of saturated fat and 3 g of sugar and Turkey Breast with Gravy 1 g of saturated fat and 2 g of sugar. It is not too difficult to see which one should be included in the Draznin Plan. The turkey breast is the number-one choice with beef tips earning second place.

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241 Living with Diabetes What else is on your shopping list If you like yogurt you should know that Dannon 99 Fat Free yogurt contains 36 g of sugar. A fat-free yogurt has 17 g of sugar and the Light’n Fit creamy yogurt contains only 10 g of sugar. When you come to the aisle where you find the English muffins you will see some with 2 g of sugar sourdough 7 g of sugar twelve-grain and 11 g of sugar cinnamon and raisin. My choice is clear the sourdough and so should yours be. High sugar content is as bad as a high content of saturated fat. Always read food labels and never go shopping hungry. We all know from our very own experience that when we are hungry we buy food items that we will later regret. Always go to the market with a shopping list you have prepared at home. If you are driving to the store and discover that you don’t have a shopping list return home and prepare one. With a list you

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Practical Advice 242 Table 11.1 Nutrient Claims and Their Meanings Term Meaning Calorie-free Fewer than 5 calories per serving Cholesterol-free Fewer than 2mg of cholesterol per serving and no more than 2 g of saturated fat per serving Fat-free Fewer than 0.5g of fat per serving Sugar-free Fewer than 0.5g of sugar per serving Low-calorie No more than 40 calories per serving Low-cholesterol No more than 20mg of cholesterol and no more than 2g of saturated fat per serving Low-fat No more than 3g of fat per serving Extra lean No more than 5g of fat 2g of saturated fat and 95mg of cholesterol per serving Lean Fewer than 10g of fat 4.5g of saturated fat and 95mg of cholesterol per serving Light or lite One-third fewer calories or 50 less fat per serving than regular food Reduced 25 less fat per serving than regular food

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Practical Advice 243

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Practical Advice 244 will buy only what you have preselected—only what you need. Without a list you will buy on the spur of the moment usually high-fat high-carbohydrate items. As you wander down the aisles examining the shelves you must understand what the nutrient claims provided by the manufacturers really mean. Table 11.1 offers a partial list for your edification. As you can see one must check labels carefully and understand ‘‘manufacturer jargon.’’ Many items contain more calories fat and sugar than may appear to be the case from reading the label. Dairy Products When you shop for dairy foods remember that they are excellent sources of calcium vitamin D and protein. A cup of

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245 Living with Diabetes skim milk for example contains 8 g of protein. At the same time there are today many ‘‘reduced-fat’’ dairy products on the market. As a rule nonfat items have little taste and many are outright unpleasant. In contrast low-fat products taste almost as good as do our favorite nonreduced items. Unless you are on a very strict low-fat diet you should still enjoy low-fat dairy products and not challenge your palate with tasteless nonfat substitutes. Conversely if you mix dairy products into recipes for example sour cream for salad dressing the nonfat kinds will do just fine. By the way instead of buying flavored yogurt you might try mixing fresh fruit into plain yogurt— do your own flavoring so to speak. Finally as an alternative to ice cream fruit-containing sorbets are delicious and they contain almost no fat and no added sugar. Meat When shopping for meat look for the leanest cuts: loin leg or round. If you are buying beef choose the ‘‘select’’ grade

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246 Living with Diabetes over the ‘‘choice’’ grade as the former is the leaner. Overall the leanest cuts of beef when trimmed of fat before cooking are eyeround top-round and sirloin steak. These cuts contain fewer than 7 g of fat. The leanest pork cut with only 4 g of fat is pork tenderloin. Trimmed boneless loin roast boneless sirloin chop and boneless loin chops contain fewer than 7 g of fat. In poultry skinless chicken and turkey are low in fat with white meat being leaner than dark meat. Always remember that ‘‘ground turkey’’ contains more fat than ‘‘ground turkey breast.’’ Duck and goose are much higher in fat than are chicken and turkey.

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Practical Advice 247 Soy Soy an excellent alternative source of protein is becoming a mainstream product for many dieters. Soy products like tofu and tempeh take on the flavor of whatever sauce marinade or seasoning you decide to use with them. There are literally hundreds of delicious and varied recipes for the preparation of soy products. The main advantage of soy products for a weight-conscious consumer is their low content of both fat and carbohydrates. For example Mori- Nu tofu one of the best-tasting tofus in my opinion contains no fat and only a single gram of carbohydrate per 3-oz serving. Snacks Unless you are slim and regularly exercise avoid all snacks and candy bars. Most commercially available snacks are not just high in fat or high in carbohydrates—instead they represent a mixture of both Most snacks are low in proteins and low in moisture.

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Practical Advice 248 They are basically designed Avoid all snacks for those who need an extra load of carbohydrates and candy bars. between bouts of moderate to strenuous exercise. If your goal is to lose weight the best you can do is to lose any interest in snack bars. Some people prefer nuts for snacks. Most nuts contain between 8 and 18 protein and 70–90 unsaturated fat. They are usually free of cholesterol. Almonds are rich in calcium and fiber. Chestnuts are unique because they contain mainly carbohydrate and are low in fat. Pecans are among the highest in fat and lowest in protein. Macadamia nuts are sweet and creamy and they have more fat and calories than do any other nuts. As a rule an ounce of nuts contains 160–200 calories.

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249 Living with Diabetes Fruit is another popular midmorning and midafternoon snack. Fruit can be fine if it is not overly sweet. Sweet fruits that contain large amounts of sugar can cause excessive release of insulin that will in turn precipitate the feeling of hunger thirty to sixty minutes after the snack. Almond or cashew butter nonfat string cheese tuna salad chicken or turkey breast avocado or a few raw nuts are examples of better snacks than fruit. Here is a list of food items you should not eat or drink if you are serious about losing weight: Asian food unless homemade without added sugar Bananas extremely high carbohydrate content Beer Breaded meat or fish Candy Deep-fried food Dry fruit very high sugar content Grapes almost pure sugar—glucose

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250 Living with Diabetes Hamburger or hot-dog buns Mixed drinks Pasta Pizza Regular soda a major culprit—high sugar content Regular bread rolls bagels and pastries Sauces most contain sugar and high amounts of sodium Sugar-coated baked food Sweet wine Watermelon oh how sweet it can be Anything that contains more than 3 g of saturated fat per serving

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Practical Advice 251 Anything that contains more than 6 g of sugar per serving except milk Here is a list of food items you should minimize in your diet if you are serious about losing weight: Cereals Dry table wine Low-calorie breads Potatoes Red meat Rice Here are some basic rules for how to maintain your diet while eating out in a restaurant: No alcohol Meat or fish grilled or broiled only

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Practical Advice 252 Meat portion no larger than the size of your palm Never anything fried deep-fried or breaded Low-calorie sauces and dressing only and served on the side No more than half a portion of the carbohydratecontaining sides such as potatoes or rice For dessert the best choice is to skip it but you can order it if no carbohydrate-containing vegetables were consumed with your entre´e order frozen yogurt light fruit pie or fresh fruit Try to have an appetizer and split the entre´e As I stated in my introductory letter at the start of this book to maintain a diet is not an easy task. In addition to your

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253 Living with Diabetes commitment the diet must be comprised of items you like to eat and must not be too complicated. Finally without increasing your energy expenditure you still may fail to lose or maintain your reduced weight. It is the entire package the Draznin Plan that you should have in mind when you embark on a journey to change your lifestyle. The rules of appropriate hypocaloric dieting can be further summarized as follows: 1. Never eat buy or bring home anything that contains more than 6 g of sugar per serving milk is the only exception. 2. Never eat buy or bring home anything that contains more than 2 g of saturated fat per serving. 3. Eat no more than six Draznin Calories per meal and no more than eighteen Draznin Calories per day. 4. Do three Draznin Miles a day.

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Chapter Twelve My Own Personal Struggle to Prevent Diabetes To Kill Diabetes Permanently Click Here am an average man—of an average size that is. I am five feet nine inches tall and weigh 176 lb which sets my body mass index BMI at 26. In order to get my BMI under the healthy ceiling of 25 I have to either drop my weight below 169 lb or grow an inch taller. Unfortunately the latter is no I

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longer an option and the former is very very difficult to do. Realistically my goal is to keep my BMI where it is now at 26. At times it was a bit greater I once tipped the scale at 185 lb the most I ever weighed. Most of the time however I’ve been reasonably successful in keeping my weight at around 174–176 lb. I am not certain whether I inherited strong longevity genes from my parents. I hope I did. We will have to live and see. If I do have longevity genes I hope to pass them on to my offspring. What I am certain about is that I have a strong family history of diabe- I have a strong family tes. Growing up I was totally unaware history of diabetes. of the medical history of my family. Alongside a handful of pleasant memories that I retain from my childhood and adolescence is the recollection that I was always hungry ‘‘A growing boy’’ my mother used to say and always 131

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256 Living with Diabetes physically active maybe even hyperactive ‘‘This kid is a fountain of energy’’ my father used to add. A Growing Boy Unencumbered by knowledge of nutrition and the dietary composition of food I ate whatever I liked. Since my favorite dish was pasta I ate a large plate of pasta every day. My mother used to prepare it for me as an after-school snack. Mainly it was a plate of penne pasta but it could be elbow bow tie eggnoodle macaroni or simple vermicelli. Pasta was my staple food—I could eat it several times a day if it were available. In contrast I never liked vegetables. I do not believe I ate a vegetable until I turned 20 years old By the same token I loved ice cream. Chocolate ice cream was the best Cold and creamy with fat and sugar added it tasted delicious I do not remember ever having enough of it. No matter how much ice cream I ate I always wanted more. No wonder I was on the chubby side of the growth curve on my pediatrician’s chart. What saved me from becoming

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257 Living with Diabetes a real blob child was my love for athletic games: soccer ice hockey volleyball team handball short- and middle- distance running long and high jump. I really loved it all. I was never among the best athletes but frequently made it to the second-tier teams and occasionally to the varsity level. Most importantly I loved the game itself much more than the outcome of a given match or meet. Once I played goalie on a soccer team and we lost 5 to 1 to another team. My teammates were crushed but I was very happy with my performance. ‘‘If it were not for my outstanding play’’ I told them after the game ‘‘the score would have been 10 to 1.’’ I made quite a few great saves I thought. It was only in medical school that I learned the medical history of my family finding out that my maternal grandfather

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My Personal Struggle to Prevent Diabetes 258 died from complications of diabetes. He had gangrene of his left foot refused amputation and succumbed to sepsis overwhelming blood infection within a few weeks. Several years later when my mother and her younger brother were diagnosed with type 2 diabetes I realized that this disease is within striking distance of me as well. As we have discussed on numerous occasions elsewhere in this book realization alone does not guarantee and does not even suggest that one will attempt or contemplate attempting making a change. The truth be known—I did very little initially. The realization had to sink in. I don’t know how long it took in terms of time but I remember growing two full sizes of clothing before I made my first change. Initiating Dietary Change This change was to give up desserts. Not easy but not too difficult either. The second step was to take up jogging on a more regular basis. I began with about twenty minutes a day building it up to thirty minutes trying to do it at least five

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My Personal Struggle to Prevent Diabetes 259 days a week. I jogged at the nearby high school track—four laps equal one mile. I tried to squeeze in between eight and twelve laps. Within four months I lost one clothing size and felt very encouraged. But the second size did not want to leave me. It was nagging and teasing me for almost two years until I made another step—practically eliminating my favorite pasta from my diet and reducing the amounts of carbohydrates I ate. This is when I added vegetables salads to my diet. Amazingly I found them just fine—very tasty that is. I realized I loved spinach salad Greek salad Caesar salad and fancy salads with fruit and nuts. I guess I did not know what I was missing But salads aside omitting pasta and reducing breads was probably the most important step at that point. My weight was

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260 Living with Diabetes coming down again. Slowly but surely. Somewhere around the same time everyone in my family began avoiding high- fat items switching to either reduced-fat or no-fat food items. We began buying nonfat milk low-fat cream cheese low-fat yogurts low-fat meat.Our eating habits began to change. Imust tell you after you remove fatty products from your diet for a year or so they no longer taste good and in fact grease becomes repulsive. New habits not only settle in but they also protect you from your previous habits. A new lifestyle is now dominant. It is harder to get away from smaller things—a candy a cookie a piece of chocolate a scoop of ice cream— particularly when they are in your cupboard and your freezer. You open the door and they smile at you—take When you open your refrigerator and the only thing that looks back out at you is an English me take me I am right here But one must learn to deal with them as well. The most important rule is to not buy them and never to

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261 Living with Diabetes cucumber you will not gain weight. bring them home. When you open your refrigerator and the only thing that looks back out at you is an English cucumber you will not gain weight. At work you might ask your coworkers not to bring sweets to the office. Most would agree. Finding the Right Exercise Program Selecting an exercise program was not as easy as I thought. Initially probably being enamored with the European and South American soccer stars and remembering fondly my childhood experience I decided to try ‘‘my foot’’ at this game. I envisioned playing games on the lush carpet of local parks on cool mornings or late afternoons. The feel of being a part of a team was also appealing. Finally I was under the impression

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My Personal Struggle to Prevent Diabetes 262 that the players run when the ball is next to you and rest when the ball is on the opposite side of the field intermittently. I found an adult co-ed league and signed up without hesitation. I was forty-five years old probably the oldest member of the team. I was proud of having been as active and as vigorous as any other member of the squad. At practices we ran kicked the ball headed it hard and navigated around red cones. The team however did not have a bona fide goalie. A few people tried but either didn’t like it or did not have the quick reaction speed necessary to play this position. The coach seemed to be convinced I was the best candidate for the job. I didn’t mind. I’d played this position before. To me the competition between the goalie and the striker shooting at the goal looked like a duel a ‘‘cat and mouse’’ play. The striker seemed to have an advantage—the goal is wide and difficult to defend. The key for the goalie as I quickly found out was to assume the correct position to always be in the way of the ball to make the shooting angle for the striker as difficult as possible. I liked my new position and was ready

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My Personal Struggle to Prevent Diabetes 263 to play. The league’s games started in two weeks. There was one thing however that I did not realize. During one of the games a long ball was kicked toward my goal. A striker from the opposite team a young man about half my age and of about my body size ran to the ball and jumped high in the air trying to head it to the goal. I ran from the opposite direction and jumped high trying to intercept the ball or at least to deflect it. We collided in the air. Two bodies bumped one another and fell on the ground. I guess I touched the ball with my stretched arm and it sailed out of bounds. Let me tell you when the bones of a forty- five-year-old man collide with the bones of a twenty-five- year-old the impact is not equal. The young striker got off the ground as if he had

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264 Living with Diabetes bounced off a soft mattress. I couldn’t move for quite a while. The pain in my neck shoulders and low back was excruciating. The coach and other players carried me off the field and placed me under a tree still stiff as a board. Another fifteen minutes passed before I was able to stand up. My soccer career ended with a great save and a bruised body that recovered only after three or four weeks. Luckily I didn’t break anything and wisely I moved to another form of exercise. Taking up tennis was my next attempt in developing habitual exercise. What a great game It looks much easier than it really is. The learning curve in one’s late forties and early fifties is steeper than I imagined. I felt as though I was spending much more time running to pick up balls than playing. Finding a suitable partner was also a problem. Most people played better than I and avoided my invitations. With others I constantly had a hard time scheduling a match. The times convenient to them were frequently inconvenient to me and vice versa. So the idea of tennis had to be replaced with another.

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265 Living with Diabetes At some point I signed up with a local hiking club a wonderful group of the most cheerful people I had met in years. The club had a schedule of weekly hikes broken down by degree of difficulty and members would select from the list. I learned fairly quickly that what they call a ‘‘moderate’’ hike represents a difficult hike for me. Instructors tended to underestimate the degree of difficulty and overestimate our ability. The most significant problem however was having to commit to weekly hikes on the weekends. This meant having to put family and frequently work obligations on the back burner. As a result even though I loved to hike the club proved to be an impractical solution. I went back to individual walking and jogging. I did not need any partners and did not need to adjust my time to fit

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My Personal Struggle to Prevent Diabetes 266 someone else’s schedule. I could do it piecemeal—a short jog in the morning and a longer walk in the afternoon. I could do it any time and place. Jogging and walking became the exercise of choice. Jogging and walking became the exercise of choice. As I was getting older it became more and more difficult to squeeze two or three miles into my daily twenty- or thirtyminute jog. I began pondering what is more important—to finish three miles or to be in motion for thirty minutes. Fortunately the natural course of events had dictated the proper answer. With time going by distance and finishing three miles required more time than the allotted thirty minutes. In addition it made me much more tired not only during and immediately after the run but also on the next day. The effect on my weight and on my vigor remains very strong if I exercise by time regardless of distance. The concept of the Draznin Mile was born that ten-minute jog or twenty-minute walk that is equal to one Draznin Mile— simple and powerfully effective. I can say this with certainty

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My Personal Struggle to Prevent Diabetes 267 because as you have learned from this chapter the Draznin Plan works even for its inventor

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Chapter Thirteen Case Studies and a Treatment Plan for Mr. K. To Kill Diabetes Permanently Click Here Ms. Elizabeth E. Ms. Elizabeth E. a forty-eight-year-old self-employed writer was the mother of two children and had no health problems except for being overweight and having type 2 diabetes. Ms. E. was five feet five inches tall and weighed

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174 lb. Her body mass index BMI was 29. Ms. E. worked from home and she was extremely disciplined about her writing and editing assignments. She allocated three hours in the morning and three hours in the afternoon to be at her desk. She also spent two hours a day reading. Aside from her usual household chores she was not involved in any ‘‘extracurricular’’ physical activity. During her second pregnancy Ms. E.’s physician detected elevated blood-sugar levels. That was sixteen years before she came to see me. At that time she was treated with three premeal injections of insulin per day. After delivery her blood-sugar levels normalized and insulin was discontinued. She did not lose much weight after her pregnancy and in fact continued to gain weight over the next five to six years. Eight years later at the age of forty she was diagnosed with overt diabetes type 2. She was started on oral antidiabetic 138

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Case Studies and a Treatment Plan for Mr. K. 270 medications and advised to follow a low-fat diet with 55 – 60 carbohydrates derived mainly from complex carbohydrates and fiber. At the time Ms. E. believed it would be easy to adhere to these new dietary recommendations particularly in light of the fact that she had always turned to pasta as a source of healthy carbohydrates and her entire household loved pasta dishes. Pasta is easy to cook and with various sauces provides great variety in taste. But her diabetes remained poorly controlled. Because Ms. E.’s blood sugar was continuously above 200 mg/dl and her glycosylated hemoglobin HbA1C hovered around 9 her doctor placed her on two injections of insulin a day. Over the next couple of months her doctor increased the dose of insulin and when Ms. E. came to see me she was taking forty-eight units of insulin in the morning and thirty-six units before dinner. Her diabetes improved somewhat with blood sugar declining to 150 mg/dl and HbA1C to 8. However after that she gained almost eighteen pounds and that generated in her a lot of anxiety frustration and unhappiness.

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Case Studies and a Treatment Plan for Mr. K. 271 Ms. E. realized that after her insulin injections she had to eat in order to prevent low blood sugar—the so-called insulin reaction. To deal with weight gain Ms. E. began skipping insulin injections first occasionally and then on a regular basis. When she came to see me To deal with weight gain Ms. E. began skipping insulin injections first occasionally and then on a regular basis. she was not taking her insulin on Tuesdays and Thursdays in an attempt to eat less on those days. She had not disclosed this to her previous physician and when I examined her her HbA1C was 9.4 reflecting almost constantly elevated blood-sugar levels. Instead of exercising

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272 Living with Diabetes Ms. E. decided to increase her physical activity by spending about two hours a day taking care of her beautiful garden. Discussion Ms. E. was an intelligent woman who had been truly and conscientiously trying to follow the recommendations she had received from her doctor. She wanted to know more about her condition and for a long time she adhered faithfully to the prescribed regimen. It was a failure of the therapeutic program that resulted in her frustration and poor compliance in taking her insulin. Eventually her fear of gaining weight prevailed over the necessity of controlling her diabetes. Unfortunately in this regard Ms. E. is not alone. Several major studies have clearly documented significant weight gain in patients receiving insulin to control their diabetes. Certainly taking increasing doses of insulin will eventually keep blood-glucose levels in check but there is a price to pay. And patients pay this price with pounds of gained weight.

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273 Living with Diabetes I asked Ms. E. to write down honestly and meticulously everything she ate during the next three days. She did and we reviewed the list of food items that made their way into her diet. Her dietary recall revealed that she was consuming an average of 3100 calories per day. That was clearly too much. To lose weight she would have to consume about one-half this amount daily. We designed a low-carbohydrate diet with a minimal amount of saturated fat and reduced cholesterol. She began a hypocaloric diet of 1600 calories per day. We also reduced her insulin dose by half and she started a walking program beginning at twenty minutes twice a day.

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Case Studies and a Treatment Plan for Mr. K. 274 The results were very impressive. Ms. E. lost eight pounds in two weeks her blood-sugar levels decreased to 120 mg/dl and we further reduced her insulin dose. The plan is for her to stay on her 1600-calorie diet build up her exercise tolerance to three Draznin Miles a day and discontinue insulin. At that time she may or may not require other antidiabetic medications. Mr. Frederick D. Mr. Frederick D. had a very different problem. He was a fortytwo-year-old loan officer with a local bank and had type 1 diabetes. He was diagnosed at fifteen years old. Ever since he had been treated with insulin injections as insulin is the only therapy for patients with type 1 diabetes. At the time he came to see me he was administering three insulin injections to himself each day. Mr. D. had never been advised to keep to a particular diet. Instead he had been taught to count carbohydrates in his diet and to adjust his insulin dose accordingly in order to cover his carbohydrate load. He had followed this advice for

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Case Studies and a Treatment Plan for Mr. K. 275 twentyseven years. He did it very efficiently having reached a certain degree of perfection in carbohydrate counting. He could look at his meals and assess the number of carbohydrates almost instantaneously. Then he would give himself a single unit of insulin for every 12 g of carbohydrates in his meal. Two years before he had undergone laser therapy on both eyes for retinal problems. A year later he had an elevated blood pressure of 150/105 mm Hg and was placed on antihypertensive medication. A month before he came to see me laboratory evaluation revealed that his kidney function was significantly impaired.

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276 Living with Diabetes He was told that within the next three to five years he would probably require either dialysis or kidney transplantation. Discussion Twenty-seven years of diabetes had finally damaged Mr. D.’s eyes and kidneys. Though laser therapy for eye problems has saved the sight of millions of patients with diabetes kidney disease remains a grave complication of the Approximately 40 of patients with type 1 diabetes end up developing kidney failure. illness. Approximately 40 of patients with type 1 diabetes end up developing kidney failure. Many require dialysis and many undergo kidney transplan- tation. Recent advances in the treatment of elevated blood pressure have reduced the rate of kidney failure in patients with diabetes but it remains a colossal

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277 Living with Diabetes problem for these people and for the health-care system in general. Major clinical studies have shown indisputably that better and tighter control of diabetes delays and prevents the development of these complications. Unfortunately some patients even those with excellent control of their diabetes can still develop complications. We do not know why this is but conceivably a certain genetic makeup may predispose these individuals to develop complications. On a side note I strongly disagree with the philosophy of ignoring diet and allowing a youngster to eat anything and everything and simply take more insulin to cover extra carbohydrates and extra calories. A number of diabetologists dietitians and psychologists believe that children and adolescents with diabetes should not be placed on dietary restrictions as these restrictions may have an adverse psychological effect. On the contrary young patients with type 1 diabetes show tremendous

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Case Studies and a Treatment Plan for Mr. K. 278 and early psychological maturity. This is true not only for patients with diabetes but also for young patients with other serious or chronic illnesses. With appropriate support it is my opinion that these children and young adults would gladly embrace the best approach to their conditions. And my approach to all patients with diabetes is to instill a firm commitment to diet therapy. Back to Mr. D. Another point of vital importance was his elevated blood pressure hypertension. Maintaining normal blood pressure is probably the single most important element in the treatment of diabetic patients with even mild hypertension. We now recognize that aggressive treatment of high blood pressure in patients with diabetes prolongs their lives delays eye and kidney complications and prevents heart attacks and stroke. A patient with diabetes should never have a blood pressure level greater than 130/85 mm Hg. Preferably it should be less than 125/80 mm Hg. It was imperative for both Mr. D. and his physician to do everything and anything possible to reduce Mr. D.’s blood pressure to desirable levels.

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Case Studies and a Treatment Plan for Mr. K. 279 I recommended that Mr. D. eliminate sugar sweets and baked goods from his diet immediately. I also designed a diet with low protein because his kidneys could no longer handle a significant protein load. The diet was also low in cholesterol and saturated fat. I would adjust his insulin intake weekly so as to find the optimal dose to control his diabetes. I began aggressive treatment of his hypertension with both medications and meditation therapy. Finally I checked his blood-lipid levels and recommended a lipid- lowering medication as well. Our hope was to delay the progression of his kidney disease which was still very much an attainable goal even in the presence of his already impaired kidney function. And what about exercise What about the three Draznin Miles for Mr. D. At that time he had to be extremely cautious

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280 Living with Diabetes with his exercise program. Strenuous exercise could further damage his kidney function. I preferred to stabilize his diabetes to control his blood pressure and then to perform a stress test. That would give us a reasonable assessment of the ability of his heart to handle an exercise load. Only at that point would I feel comfortable designing an exercise program for Mr. D. Now after we have discussed in detail the role of diet and exercise in weight reduction and weight maintenance we should be able to give very specific recommendations to many other individuals with obesity and diabetes. I wish to present to you several case studies examples from my clinical practice and ask you the reader to

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281 Living with Diabetes I want to ensure not only that you read my book for its general educational value but also that you derive from it specific information that will be important in helping you address your own concerns with a clearer understanding of them. participate with me in the decision-making process. I want to ensure not only that you read my book for its general educational value but also that you derive from it specific information that will be important in helping you address your own concerns with a clearer understanding of them. The examples I offer to your attention should mirror some of the problems you might have and they should help you solidify the knowledge you have gained from this book. I hope these case studies will also reinforce the notion that every person is different and that advice should be

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282 Living with Diabetes individualized as much as possible. At the end of this exercise we will design a very specific program for Mr. Jeffrey K. who is still sitting in my office awaiting answers.

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Case Studies and a Treatment Plan for Mr. K. 283 Case Study 1 Jason P. age twelve came to see me because of a recent weight gain of approximately eighteen pounds. Even though Jason had grown about four inches over the previous summer and fall an eighteen-pound weight gain rightly alarmed his parents who brought Jason to my office. Jason’s father was an engineer with a cable company and his mother worked as a billing clerk for a group of physicians. Jason had grown up normally with minimal medical problems. Over the previous year he had become very involved with his computer and now spent almost all his free time in front of his PC. Though his parents were very proud of his ability to write computer programs and design sophisticated Web pages they were concerned with his recent weight gain. For breakfast Jason usually had a glass of orange juice and a blueberry muffin. He would have a bag of chips and a can of regular Coke at school and he would eat about two servings of macaroni and cheese when he arrived home from school. He would then eat again at 7:00 PM this time dinner with his family. The meal usually consisted of things like

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Case Studies and a Treatment Plan for Mr. K. 284 chicken with mashed potatoes or pizza. Jason would drink another can of regular Coke at the dinner table. A large-sized bag of corn chips and a Coke were always present at his computer desk and he wouldn’t even notice how many chips he ate at his computer. Question. What should Jason do to prevent further weight gain and possibly lose excess weight in the near future Answer. Clearly the computer had consumed Jason to the point that he had neither the time nor the desire to be involved in any physical activity. At the same time his diet was extremely

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285 Living with Diabetes rich in carbohydrates. On this diet and without exercise Jason was about to join the increasing ranks of obese children and young adults. Before it was too late his parents should convince Jason or lead him by example to allocate some time in his daily routine for physical activities: walking biking playing basketball swimming—anything but sitting in front of a PC monitor. Dietary habits would also have to be altered. Muffins macaroni pizza and regular Coke—all must go. Vegetables fruit noncaloric drinks and nonfat meat and poultry would have to be introduced into his diet. In order to place a twelve-year-old on a diet all members of the household would have to change their dietary habits. It was absolutely mandatory for Jason to reverse his course toward obesity. Question. For which one of the following four twelve- yearolds is a macaroni-and-cheese dinner not an appropriate choice

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286 Living with Diabetes a. A very active twelve-year-old boy who also plays soccer every day. b. A normal-weight twelve-year-old boy who spends most of the day in front of his computer. c. A normal-weight twelve-year-old girl who is a member of a competitive swim team. d. A normal-weight twelve-year-old girl recovering from surgery for a broken leg. The answer is b. All four children eat an unrestricted diet making it very likely that the sedentary child who spends most of his day in front of a computer monitor consumes more than he spends. This sedentary youngster will quickly become over-

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Case Studies and a Treatment Plan for Mr. K. 287 weight on a high-carbohydrate and high-fat diet. The girl recovering from surgery will have to adjust her diet when recovery is complete. Case Study 2 Ms. Marianne Z. a five-foot seven-inch woman weighing 185 lb worked as a paralegal in a busy law office. She was thirty-five years old and had two children ages five and seven. She had gained twenty pounds after the birth of her first child and over thirty pounds during and after her second pregnancy. Her thyroid-function tests were normal and she did not have diabetes. Ms. Z. loved sweets and pastries and she prepared a lot of sweet food items for her family. Pancakes with honey cinnamon rolls and Belgian waffles were her favorite breakfast foods. She had read that fatty food is bad and she was trying conscientiously to buy low- fat items. She loved to bake and was proud of her culinary skills. She stayed busy at work and at home but she was not involved in any structured exercise program.

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Case Studies and a Treatment Plan for Mr. K. 288 Question. What should Ms. Z. do to initiate weight loss Answer. The very first thing Ms. Z. needed to do was to begin a hypocaloric diet. She had to eat less. She had to consume fewer calories than she expended. This was unquestionably the number-one rule for her success. Ms. Z would have to change the nature of the food she ate the way she cooked and the food items she purchased. Many so-called low-fat foods contain excessive amounts of sugar and other carbohydrates that are not good for weight loss. Among her immediate steps Ms. Z. had to switch herself and the entire

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289 Living with Diabetes Many so-called low-fat foods contain excessive amounts of sugar and other carbohydrates that are not good for weight loss. family to noncaloric beverages change her breakfast routine and eliminate 90 of her baking. Without these steps she would never be successful in losing or even maintaining her weight. Subsequently she would have to find time for three Draznin Miles a day. Question. What is the most appropriate breakfast choice for a five-foot seven-inch woman weighing 185 lb a. One egg over easy one slice of whole wheat toast one unsweetened grapefruit. b. One pancake with honey a glass of orange juice. c. One cinnamon roll with marmalade coffee with skim milk.

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290 Living with Diabetes The answer is a. This is the only choice that minimizes the intake of carbohydrates. Choices b and c would fit a highcarbohydrate diet and would be highly inappropriate for an obese woman. Case Study 3 Mr. Dwayne J. was a forty-two-year-old sales representative who was six feet tall and weighed 195 lb. He traveled extensively within the western United States staying in hotels and eating out with his clients and colleagues. During the previous four years he had gained twenty-five pounds. He had mild pain in his knees that limited his ability to walk which he actually liked to do but for which he could find little time. Recently his blood pressure had risen to 140/95 mm Hg.

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Case Studies and a Treatment Plan for Mr. K. 291 He knew about some ‘‘minor’’ problem with his cholesterol but he didn’t remember what exactly it was. He was otherwise healthy. His father had died of a heart attack at the age of fifty-nine. Question. What should Mr. J. do to lose weight Answer. At the age of forty-two with elevated blood pressure probably elevated cholesterol and a family history of a heart attack Mr. J. had first to undergo an exercise stress test and then we would reevaluate his lipid levels. Provided he was ready for it Mr. J. ought immediately to start an exercise program building up to three Draznin Miles a day. Considering his knee pain stationary biking or swimming might be his best options. He should also start a hypocaloric diet eliminating high-fat and high-carbohydrate items. His new diet should consist of grilled meat and fish with vegetables. It goes without saying that he should stop drinking alcohol either before or with his meals.

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Case Studies and a Treatment Plan for Mr. K. 292 Question. Which one of these four 195-lb individuals should not eat a 900-calorie shrimp-and-pasta dinner a. A five-foot eleven-inch college student competing for a spot on a football team. b. A five-foot seven-inch thirty-five-year-old former high school and college wrestler who works out and jogs three miles daily. c. A five-foot nine-inch thirty-nine-year-old lawyer who is trying to lose weight. d. A six-foot two-inch thirty-four-year-old auto mechanic who is on a low-fat diet.

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293 Living with Diabetes The answer is c. A high-carbohydrate meal would not be beneficial to a sedentary person who is trying to lose weight. It might however be appropriate for an athletic person who is involved in a regular more than moderate exercise program. I hope you have answered all these questions correctly. Let us now return to Mr. Jeffrey K. our protagonist and my patient waiting to hear my advice regarding his weight diabetes and high blood pressure. Without becoming engulfed in many small details for the purpose of our discussion I submit to you that my advice will be concerned with four general areas: diet exercise lifestyle and medications. Because the ‘‘medication’’ topic is too specific and highly professional it is clearly beyond the scope of this book. Let us put it aside and discuss my recommendations for diet exercise and lifestyle in great detail. First there is a sensible and realistic hope for Mr. K. Two large studies have confirmed what many of us already knew from our individual ex-

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294 Living with Diabetes Two large studies have confirmed what many of us already knew from our individual experiences: Appropriate diet and exercise prevented the development of diabetes in almost 60 of people participating in these studies. periences: Appropriate diet and exercise prevented the development of diabetes in almost 60 of people participating in these studies. In a Finnish study 172 middle-aged and over- weight men and 350 women achieved on average a 4- kg 8.8-lb weight loss in one year. They maintained a 3.5- kg 7.7-lb weight loss during the second year of the study as well. At the end of the second year the risk of these individuals’ developing diabetes was reduced by 58

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Case Studies and a Treatment Plan for Mr. K. 295 A second study was conducted in the United States. A large clinical trial called the Diabetes Prevention Program enrolled 3234 participants with impaired glucose tolerance a condition that commonly leads to diabetes. On a low-fat diet and with exercise of 150 minutes each week these individuals also reduced their risk of developing diabetes by 58 Splendid wonderful and encouraging news for Mr. K. His chances of winning his battle with his early diabetes are greater than 50 Diet Mr. K. weighs 230 lb and is six feet tall. Because his ideal body weight is approximately 180 lb he has a long way to go. If we establish a fifty-pound weight reduction as our initial goal we will most likely fail. This goal is simply unrealistic at this point. We should be much more modest and set our goal at a twentypound weight loss within the first year getting Mr. K. down to 210 lb. This will be a loss of approximately 8 of his starting weight. If he is successful

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Case Studies and a Treatment Plan for Mr. K. 296 in attaining this goal and maintaining his reduced weight we might revise our goals and expectations but for now this 8 weight loss seems to be a realistic and achievable goal. The very first thing I want Mr. K. to do is to keep a precise list of what he eats—a diary or ‘‘dietary recall’’ as it is called. Whatever food item makes its way to Mr. K.’s mouth has to be recorded in his food diary. This is the only way to objectively monitor what he eats to analyze his caloric intake and to make appropriate adjustments. After a certain period of time under my guidance he will learn to make these adjustments on his own. Some people object to keeping such a list arguing that this exercise focuses them on their problems instead of allowing them to live free of them. I believe that maintaining this

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297 Living with Diabetes list strengthens our commitment to weight-reduction goals. After all we are on a lifelong mission to change the way we eat and the way we live. I will also ask Mr. K. to eliminate from his home and from his diet margarine candies pastries flour sugar cereals sour cream whipped cream pasta beer and all other items that contain more than 6 g of sugar and/or 2 g of saturated fat per serving. I also want Mr. K. and his wife to spend an hour twice a week in their favorite grocery store reading and comparing labels of various food items—those that they used to buy and those that they will be buying from now on. They must understand what they are purchasing. I invited Ms. K. to accompany her husband to his next appointment with me. She is an integral member of our team and her support understanding and cooperation are absolutely critical. Table 13.1 is a sample menu that the three of us decided would be acceptable for Mr. K. A number of variations can be introduced to this basic menu but the goal remains the same— to design a hypocaloric diet containing no more than

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298 Living with Diabetes eighteen Draznin Calories a day between 1500 and 1800 calories with moderate amounts of carbohydrates. Exercise Jeffrey K. is a very sedentary man but he does not have any other health problems aside from his recently diagnosed diabetes and mild hypertension. He is also over thirty-five years of age and I would like to see a normal exercise stress test before recommending an exercise program to him even one as simple as three Draznin Miles. Once the stress test clears him for an exercise program he can easily start his way to the three Draznin Miles a day program. He can accomplish this by walking

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Case Studies and a Treatment Plan for Mr. K. 299 Table 13.1 Sample Menu for Mr. K Breakfast One soft- or hard-boiled egg can be pan-fried with a nonstick spray One slice of whole wheat bread or toast preferably low-calorie bread ½ cup of berries or 2 slices of melon Water tea or coffee Midmorning Snack Cup of tea with 1 small apple 5 almonds or a slice of cheese Lunch Big bowl of salad with low-fat dressing Grilled chicken turkey breast or tuna Water tea or diet soda Midafternoon Snack 8–10 peeled small carrots 1 apple or pear Water diet soda or tea Dinner

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Case Studies and a Treatment Plan for Mr. K. 300 Large salad with low-fat dressing Grilled meat poultry or fish Steamed or stir-fried vegetables 1 cup of berries or 2 slices of melon or watermelon Sugarless fruit popsicle Water tea or coffee ten minutes away from his home and ten minutes back twice a day. I want him to do this for three weeks and then increase his walking distance to fifteen minutes each way. This would translate into an hour a day of walking This is a great goal for the next couple of months. The magic three Draznin Miles a day are within his reach. Meanwhile I want Mr. K. to buy a pair of new and comfortable walking shoes and a pedometer. Realizing that the goal

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301 Living with Diabetes is to take at least 10000–11000 steps daily he should know where he stands right now and the progress he will be making on his way to the goal. I firmly believe that even a small investment will offer a huge boost to his motivation. Lifestyle Changing his diet and embarking on a walking program are already great improvements in Mr. K.’s lifestyle. But we want more. Fortunately he does not smoke and he drinks only minimal amounts of wine. I do not believe it will be difficult for him to abstain from alcohol. I want Mr. and Ms. K. to find out what kinds of meditation and yoga classes are available in their community. I want them to visit some of these programs and speak to the instructors. We plan to discuss their findings about a month from now when they are somewhat adjusted to their new diet and exercise routine. We shake hands and Mr. K. leaves my office. He will return in a week after his exercise test with Ms. K. and an initial report on his progress. He will certainly bring the list

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302 Living with Diabetes of food items he has eaten during the week. We will recheck his bloodsugar level and blood pressure and spend some time together. We will have taken the first two steps on his long road to success. We come at last to conclusions to the summary of my thoughts. You are now the master of the Draznin Plan. Remember the third leg of the Draznin Plan’s foundation— the three-legged stool—your personal commitment. Now that you know everything else your personal commitment has become a key to your success. Do not get discouraged by temporary setbacks. You are only human—you fall off the wagon so get back in as soon as you can. Time flies fast as it is you cannot

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Case Studies and a Treatment Plan for Mr. K. 303 afford to lose extra days and weeks. It is not that overwhelmingly difficult. After all you have learned to brush your teeth wash your hands as well as fruit and vegetables greet your neighbors and thank people who do something nice for you. I am absolutely convinced you can build another habit—to do three Draznin miles a day and avoid sweets and fats in your diet. One of the greatest improvements in human health came with the realization that water must be boiled before use. This one simple as we now know step saved millions of lives. Unfortunately and sadly there are still places in the world where this is not done. But we are beyond this. Our next major battle is self-indulgence—too much food too little effort. I believe that once we understand this we can deal with the problem. My plan does. With your commitment you will be able to do it. Try it and write to me—Boris.Drazninuchsc.edu. Good luck It was a great pleasure writing my plan for you.

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Appendix A Recommendations Based on Ten Draznin Rules of Life To Kill Diabetes Permanently Click Here Science is the orderly arrangement of what at the moment seem to be the facts. Anonymous

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Recommendation 1 Three Draznin Miles and fewer than eighteen Draznin Calories a day are the keys to your successful fight with obesity and diabetes. Recommendation 2 Select a knowledgeable doctor who has both the interest and the time to discuss your lifestyle problems with you. Recommendation 3 Develop a set of reasonable goals and tackle them one by one. Recommendation 4 Do not stay on a very low–calorie diet for more than ten days. Rather always be on a hypocaloric diet that has been developed to meet your goals. 157

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307 Appendix A Recommendation 5 Always stay on a low-carbohydrate diet unless your body mass index is under 25 and you do at least six Draznin Miles a day. Recommendation 6 Exclude saturated fat from your diet but do not be afraid of mono- and polyunsaturated fats. Remember that a Mediterranean diet based on these fats is both healthy and tasty. Recommendation 7 Never eat or drink anything that contains more than 6 g of sugar per serving. Recommendation 8

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308 Appendix Remember that at every stage of your life you are personally responsible for at least 90 of its quality. Recommendation 9 He who would eat the kernel must crack the nut. You must have a lifelong commitment to your lifestyle choices. It is never too late to start your commitment. Recommendation 10 Never forget Recommendation 1

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Appendix B Frequently Asked Questions To Kill Diabetes Permanently Click Here eople in general and my patients are not an exception always have questions about their health. I do everything possible to encourage my patients not only to generate these questions but to bring them to my attention. Their questions reflect the individuality of their problems P

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and I hope my answers boost their confidence in adherence to and compliance with their treatment plans. What follow are typical questions my patients ask followed by short answers that might be helpful to you. I will also tell you how to contact me and make use of other sources to help answer questions and concerns you have. Question 1. I started on your program about three months ago and I am still doing fairly well with the dietary part. However it’s the walking part that gives me trouble. I’ve built up my walking program to twenty minutes a day and I just don’t seem to have time either in the morning or in the evening to increase my exercise. I leave home early return about 600. we eat dinner at 6:30 or 7:00 and after dinner I am too tired to go out. I watch TV for about an hour and then read 159

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311 Appendix B in bed for about twenty to thirty minutes. Do you have any suggestions as to how I can deal with my problem Answer 1. I understand that you have a long workday and find it difficult to squeeze in more exercise. We can deal with this in several ways. First there is a wonderful program developed at the University of Colorado Health Science Center under the direction of Dr. James Hill. Participants are asked to wear a pedometer a little gizmo that is worn on the belt and counts the number of steps one makes. After a week a staff member calculates the average number of steps the participant did daily and asks him or her to add 2000 steps every day. These 2000 steps can be made at any time during the day. They can come from walking an extra flight of stairs parking your car farther away in the parking lot and walking the extra distance or making another circle around the park. The 2000 steps represent about one mile and adding them to your daily walking regimen can go a long way toward your three Draznin Miles a day.

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312 Appendix B The second way of finding time to exercise is to use the time you watch TV. This way is a bit more expensive. You should purchase a treadmill place it in front of your TV and use it while watching your favorite program. Personally if I watch a sporting event I do it only while walking on my treadmill. Question 2. I have noticed that lately both my husband and I feel extremely anxious about several things in our lives. things like job security pension funds our teenage children and our elderly parents. Every time I worry about one of these things I feel hungry I eat and not surprisingly I gain weight. Is there a relationship between anxiety and weight gain

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Appendix B 313 Answer 2. Very much so even though no one knows the exact nature of this relationship. Conceivably chemical and/or hormonal imbalance in the brain can be the culprit. Brain cells misfire disconnect lose inhibitory control and become incompetent in regulating the sense of satiety. At the same time anxiety can be accompanied by increased output of adrenaline which can change the levels of glucose in the blood and consequently the levels of insulin and the sensation of hunger. Let me share with you a story about my patient Mr. Zi. Mr. Zi is a private investigator who also repossesses automobiles on behalf of lenders when people default on their loans. He converted a process of repossession into an art of towing away a car within forty-five seconds a sort of legalized car theft. During these quick operations they must be quick to avoid an altercation with an irate owner he is focused concentrated on his task and extremely anxious. Approximately twenty to thirty minutes after the towing he feels thirsty and extremely hungry. Mr. Zi has gained over thirty pounds in the span of two years despite being

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Appendix B 314 reasonably active at work and in the gym. I believe that the anxiety of Mr. Zi’s job caused his weight gain and that the treatment of anxiety and elimination of anxietyprovoking factors should come first before any successful diet can be instituted. Question 3. Every day I try to eat a light lunch such as a salad or just a cup of soup. I feel fine for about an hour or two but then I become terribly hungry. I can no longer concentrate on my work. I go through our large office searching for candies or cookies that many of my coworkers keep around. I tried bringing some fruit from home but this didn’t help I was still extremely hungry. How shall I deal with my bouts of midafternoon hunger

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315 Appendix B Answer 3. This is probably the biggest problem with dieting. Regardless of the type of diet we follow when we become hungry it is very difficult to adhere to any program. Hunger is a dominant feeling. When we are really hungry our mind is completely preoccupied with food. The thought of subsequent regret is driven away the hunger prevails and behavior is dominated by a search for food. We become overwhelmed by the hunger-driven inability to maintain our dietary program. I must say at the outset this problem is extremely common and there is nothing to be ashamed of. It is also a losing proposition trying to fight one’s hunger by evoking the remnants of one’s willpower. The only way to succeed is to change the environment in which we find ourselves at the time we feel hungry to get away from food and to switch our mind to something completely different that can occupy us for a while. I recommend that the minute you feel this uncontrollable hunger after that small lunch that you were supposed to eat to stay on your diet you leave your house if you are at

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316 Appendix B home. Go for a walk go to the library a bookstore a department store a museum—anywhere to be away from food and better yet where your mind can become engaged in a totally new activity such as reading analyzing comparing calculating making plans and so forth. Certainly this is much harder to do at work. When you remain hungry after lunch sitting at your desk with your mind overwhelmed with thoughts of food first try sipping water or a noncaloric drink. Frequently small sips curb your feeling of hunger. If this doesn’t help a dozen almonds or a stick of string cheese is the next line of defense. Still the best approach to this residual hunger is to get truly busy and to be away from food.

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Appendix B 317 Schedule a meeting discuss work-related problems get busy with manual tasks—do anything that takes your mind away from food. Question4. Someone told me that eating twice a day is the best way to lose weight. I tried this but found it difficult not to eat between breakfast and dinner. What is a good interval of time between meals Answer 4. I recommend that you eat every five to six hours during daytime. For example eat at 800. AM 1:00 PM and 6:00–7:00 PM. I also stress that the time interval between the end of your dinner and your next breakfast be no less than twelve hours. If you finish your dinner at 8:00 PM do not eat your breakfast before 8:00 the next morning. Question 5. I’ve been looking for a diet that I can stick to without making a huge effort to find the ‘‘right’’ food items or perfect cooking style. What is the simplest and the most

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Appendix B 318 effective diet for a man who wants to lose ten to fifteen pounds Answer 5. The Draznin Calorie plan allows you to eat any grilled low-fat meat poultry or fish with most of the vegetables except potatoes and corn and a variety of fruit except grapes and bananas. If you stay with these recommendations you can lose ten to fifteen pounds within three months easily. Question 6. I weigh 265 lb and I have type 2 diabetes that I am treating with a total of 114 units of insulin taken in three separate injections. I am ready to go on a strict low-calorie diet. How do I adjust my insulin Do I stop it altogether

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319 Appendix B Answer 6. Most likely you can cut your insulin dose in half without any problems provided you are serious about trimming your food intake and you measure your blood sugar levels four times a day. Several years ago my colleagues and I conducted a study in which we recommended our overweight diabetic patients fast for five days drinking only noncaloric fluids before initiating dietary therapy. These patients did not take any insulin during this complete five-day fast and they resumed taking it afterward depending upon their blood-sugar readings. These patients did very well and only half of them required insulin after this initial fast. The danger arises if you reduce your insulin dose but do not reduce what you eat and do not check your blood-sugar levels. Clearly working with your doctor or diabetes educator is preferable to doing it alone. Question 7. I am five feet six inches and weigh 208 lb. I am taking two pills for my lipids two for diabetes two for high blood pressure one aspirin and multivitamins. I have recently gained seven pounds and my blood sugar is just

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320 Appendix B above 200 mg/ dl. I was told to start taking another medication that might prevent absorption of sugars. Is there another way to achieve better control of my problems without so many pills Answer 7. Losing weight will help tremendously. Most likely your diabetes will improve and quite likely your blood pressure and lipids will also improve. You seem to be a prime candidate for the Draznin Plan if you are ready to embark on this program. I also recommend meditation classes for mild hypertension and for learning to take control of your problems. Question8. I work out in the gym three times a week and I cut down on the carbohydrates in my diet. I am really trying to

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Appendix B 321 eat healthy—fruits and vegetables. I drink a lot of fruit juices not sodas—four to six glasses of orange or cranberry juice a day. Yet I have lost only two pounds in the last four months. Is there anything else I should be doing Answer 8. Unfortunately yours is a common mistake. Fruit juices are extremely caloric with simple sugars accounting for most of the calories. I firmly recommend that any fluid you consume except for milk should contain no calories. Stopping fruit juices would be my immediate recommendation. Question 9. I followed your program for over six months and I lost eighteen pounds. I now weigh 192 lb down from 210. I walk an hour every day but during the last three weeks I haven’t lost any more weight. How do I get on the weightlosing track again

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Appendix B 322 Answer 9. An excellent question. Remember the first goal of the Draznin Plan is to help you lose about 10 of your initial weight and maintain the reduced weight for about six to twelve months. At this point one must reevaluate the program and make the next step. For example if you are not doing three Draznin Miles a day you should make an effort to get to this goal. If you do you might want to increase your walking or jogging speed or possibly extend the time by an additional ten minutes a day. You can add 2000 steps daily or be a little stricter about your diet. Question 10. I have learned to take boredom out of my daily walks—I listen to books on tape as I stroll through our neighborhood around a small park and back home. It works well. It’s the dietary part that I find more difficult to follow

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323 Appendix B simply because my choices are somewhat limited. In other words the diet is boring. What would you suggest Answer 10. I would recommend expanding the variety of meat or fish you are buying and of the vegetables you eat. There are wonderful recipes in vegetarian cookbooks that you can adopt as well as numerous types of fish and nonfat meat that you can grill or sear. Adding various spices may also help. Question 11. My blood-sugar levels hover around 220 mg/dl. My doctor tried me on three different medications but they didn’t seem to help. My weight is 190 lb and my doctor tells me that unless I lose weight he will have to start me on insulin. Is there anything else I can do Answer 11. Your doctor is absolutely correct to suggest that controlling your blood sugar is your number one priority. However you can help yourself and your doctor to

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324 Appendix B accomplish this task by losing weight. In this case you may avoid insulin altogether. A lot of control over your health in your own hands. Question 12. My twenty-two-year-old daughter weighs 186 lb and is only five feet four inches tall. Most importantly however she refuses to do anything about her weight. She says she feels good about herself enjoys her friends and her lifestyle and is proud to be who she is. On the one hand I am glad she is not depressed and that she maintains her self- confidence on the other hand I am very much concerned and don’t know how to help her. Your advice Answer12. Unfortunately your ability to help is limited at this point. A direct discussion or repeated confrontations will not

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Appendix B 325 help. You might work indirectly so to speak. Invite her for walks hikes bike rides or a swim. Change the way you cook at home and it is hoped she will like the new recipes. Suggest that she consult a psychologist perhaps for some other reason if such exists and then recommend to your daughter that she talk with the psychologist about her weight. This is not an easy task it will certainly take some time but being concerned about it is the first step. Question 13. If I have a question about my weight maintenance or my diabetes how can I contact you Answer 13. You can find me at the University of Colorado Health Sciences Center. In addition you can obtain valuable information from numerous excellent Web sites related to diabetes appropriately led by the American Diabetes Association www.diabetes.org the Juvenile Diabetes Federation www. jdf.org the International Diabetes Federation www.idf.org the British Diabetes Association

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Appendix B 326 www.diabetes.org.uk and the Joslin Diabetes Center www.joslin.harvard.edu.

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Resources American Diabetes Association ATTN: National Call Center 1701 North Beauregard Street Alexandria VA 22311 1-800- DIABETES www.newdiabetesmedications.com American Dietetic Association 120 South Riverside Plaza Suite 2000 Chicago IL 60606-6995 1-800- 877-1600

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www.newdiabetesmedications.com American Heart Association National Center 7272 Greenville Avenue Dallas TX 75231 1-800- AHA-USA -1 www.americanheart.org American Society for Nutrition 9650 Rockville Pike Bethesda MD 20814 1-301-634- 7050 www.newdiabetesmedications.com 169

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330 Resources Joslin Diabetes Center One Joslin Place Boston MA 02215 1-617- 732-2400 www.newdiabetesmedications.co m National Diabetes Information Clearinghouse 1 Information Way Bethesda MD 20892-3560 1-800-860- 8747 www.newdiabetesmedications.com NAASO The Obesity Society 8630 Fenton Street Suite 918 Silver Spring MD 20910 1- 301-563-6526 www.newdiabetesmedications.co m

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Index AARP 19 Absorption-modulating medications 32–33 93 Absorption of food 29 31–33 Acarbose 53 Activity thermogenesis AT 29 Actos pioglitazone 96 Adenosine triphosphate ATP 53 Adolescents. See Children and adolescents African Americans 24 Age activity levels and 36–37 Aged obesity in 19 Alcoholic beverages 117–118 Alpha-glucosidase inhibitors 32 American Association of Retired Persons AARP 19 American Diabetes Association care guidelines 77 Americans obesity in 18–19 Amino acids 53 54 Amish obesity in 20–21 Amputations 25 Anecdotal stories 4 Antioxidants 122 Anxiety and weight gain 160–161 Appetite regulation 50–51 63 65 118. See also Hunger Asian food 119 AT activity thermogenesis 29 Atherosclerosis 25 Atkins diet 63–64 66 67 ATP adenosine triphosphate 53 Avandia rosiglitazone 96 Bariatric surgery 86 95 – 96 Basal metabolic rate BMR 29 33 –34 52 62 Beef cuts 126 Beverages 117–118 165 Bicycling 43 – 44 Blindness 25 – 26 Blood pressure high 141 143

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Blood-sugar levels. See also Glucose alcohol consumption and 118 exercise and 69 – 70 glycemic index and 113 insulin and 47 normal values 8 BMI. See Body mass index BMR. See Basal metabolic rate Body fat. See Fat body Body mass index BMI 15–17 24 Body weight ideal 14 – 15 Boredom walking and 42 Breakfasts sample 107 108 153 Caloric density of food 89–90 105 122 Caloric intake recommendations 87 171

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333 Index Calorie restriction. See also Hypocaloric diets severe 62 157 Calories. See also Draznin Calorie absorption of 31–33 defined 29–30 104 Draznin Calorie equivalent 106 expenditure through exercise 39 40 per gram of carbohydrates proteins and fats 54 per pound of fat 30 utilization of 29–30 33–35 Carbohydrates dietary. See also Sugars dietary calories per gram 54 C-reactive protein and 25 digestion of 32–33 47 insulin release and 68 insulin resistance and 66 metabolism of 53 54 55–56 68 previous recommendations for 21–22 recommended intake of 48 115– 116 123–124 130 simple vs. complex 112 Case studies childhood weight gain 145–147 diet modification for obese woman 147–148 early diabetes 7–9 59– 62 150–154 individualization of therapy 72 74–76 79–80 low-fat diet limitations 56–58 obesity with high heart disease risk 148–149 plateau in weight loss 98–99 type 1 diabetes with complications 141–144 type 2 diabetes with poorly controlled blood sugar 138–141 Children and adolescents activity levels of 20–21 36 case study 145–147 obesity in 18 19–21 type 1 diabetes in 47 Cholesterol 64 116 Cognitive function 102–103 Commitment 5 154–155 158 Consumer Reports study 14 C-reactive protein 25 Cycling 43 – 44 Dairy products 125–126 Dansinger Michael 66 Davis Gary J. 16 Death risk of body weight measures and 14 15 16 diabetes and 24 obesity and 19 Declarative learning 102 Depression and overeating 89

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334 Index Diabetes. See also Prediabetes specific topics complications of vii 25–26 44 – 45 141–142 143 death rate from 24 diagnostic criteria for 8 individualized care for 5 72 – 79 insulin for 47 142 143 163–164 medications for 96 – 97 prevalence of v 23 – 24 sources of information on 167 169–170 types of. See Diabetes type 1 Diabetes type 2 Diabetes type 1 47 49 141–144 Diabetes type 2 case studies 59–62 138–141 150–154 Draznin family history 132–133 insulin resistance and 4 49 66 70 obesity and 15 23– 24 25 prevention of vii–viii 3–4 96 –97 150–151 risk factors for 23 – 24 Diabetic care guidelines 77 Diabetics health survey of 78 Diabetologists 78 Diagnostic criteria for diabetes 8 Dietary guidelines Draznin. See Draznin Calorie in past 21–23 88 Dietary Guidelines for Americans 112 Dietary restrictions in diabetes treatment 142 Dieters demographics of 13 – 14 Dieting. See also Weight loss Draznin experience 133–134 insulin therapy and 163–164

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motivation for 6 success rates in 13–14 60 Diets case study example 151–152 component balance of 65–67 C- reactive protein and 25 high- carbohydrate diets 21–23 25 56–58 66 88 high-protein high-fat diets. See Low-carbohydrate diets historical recommendations on 21–23 88 hypocaloric 60–66 86 111–112 130 popular studies comparing 66–67. See also Atkins diet Ornish diet Sugar Busters diet Zone diet variety in 163 166 Digestion 29 32–33 47 116 Dinner menus sample 108 109 153 Disaccharides 112 Disinhibition 89 Doctors. See Physicians Draznin Boris 131–137 167 Draznin Calorie caloric equivalent of 106 concept of 11 105–106 meal planning with 106–110 values for common food items 107 Draznin Mile alternative exercise forms 43 – 45 duration of exercise and 11 38 getting started 41–43 jogging 39 41 42–43 walking 40–42 Draznin Plan 4–5 11–12 130 157–158 Draznin Rules 20 27 36 39 40 48 67 119 recommendations based on 157– 158 Drugs. See Medications Eating at home 108 122–123 Eating behavior 87–89 Eating out 108 119–120 129 Elderly obesity in 19 Emotional imbalance and overeating 89 Endocrinologists 78 Energy. See also Calories utilization of 33–34 55 Index 173 Energy balance 4–5 28–31 55 61 Energy gap 100–101 Energy value of foods 89 – 92 Environmental factors 20–23 30 – 31 Ephedra 94 Essential amino acids 54 Ethnicity diabetes risk and 24 Europeans obesity in 18 Evidence-based medicine 4 – 5 Executive cognitive function 103

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Exercise. See also Draznin Mile age and 36 – 37 attrition rates 83 – 84 benefits of 37 – 38 blood-sugar levels and 69 – 70 case study 152– 154 Draznin experience 134–137 energy expenditures of 29 39 40 finding time for 159– 160 forms of 43–45. See also Jogging Walking high- carbohydrate diets and 22 insulin resistance and 70 intensity of 39 obesity in children and 20 – 21 precautions when starting 44 – 45 weight loss and 4–5 67 68–69 71 Eye disease 25– 26 44 141 143 Fast five-day 164 Fat body distribution of 17 energy balance and 28–29 52 Fat metabolism 48 49–50 53 54 55 – 56 Fats dietary caloric conversion factors 30 54 digestion of 32 116 low-fat diet craze 22–23 88 recommended intake of 67 90 – 91 116–117 126 130 saturated vs. unsaturated 116–117 types of 116 Fatty acids 53 54 70–71 116–117 Fenfluramine 51 94 Fen-phen 51 94 Fish dishes 119

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337 Index Fitness body mass index and 17 Food absorption of 29 31–33 93 caloric density of 89–90 105 122 changes in consumption of 21–23 digestion of 29 32–33 47 116 Draznin Calorie equivalents of common items 107 enjoyment of 6 types to avoid or minimize 128–129 Food diary 151–152 Food Guide Pyramid 23 Food labels 23 90 105 108–109 Food preparation 122–123 Fried foods 119 120 Fruit 128 Fruit juices 165 Frustration 60 Gardner Christopher 67 Gastric bypass surgery 95 Gastric restriction surgery 95 Gender differences 24 39–40 87 Genetic factors 20 27–28 30–31 GI glycemic index 113–116 Glaucoma 25–26 Glucose. See also Blood-sugar levels production of 53 54 68 storage of excess 48 55 68 utilization of 34–35 47–48 55–56 Glucose tolerance impaired 151 Glycemic index GI 113–116 Glycerol production 53 54 Glycogen 48 52 54 55 68–69 Glycogenesis 68 Goal setting 84 99–100 157 Grocery shopping 123–125 Guru Walla tribe 56 Habit formation 102–103 Harris Maureen 78 Heart disease 25 44 45 Herbal medications 94 High blood pressure 141 143 High-carbohydrate diets 21–23 25 56– 58 66 88 High-fat diets. See Low-carbohydrate diets High-protein diets. See Low-carbohydrate diets Hill James 100 159–160 Hispanic Americans 24 Home-cooked meals 108 122–123 Hormones and weight regulation 49 – 50 Hunger 50 89 105 161–163. See also Appetite regulation

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338 Index Hypertension 141 143 Hypocaloric diets 60–66 86 111–112 130 Hypothalamus 50 51 Impaired glucose tolerance 151 Impotence 25 Individualized program design 5 76 – 79 Insulin appetite and 65 deficiency of. See Diabetes type 1 fat storage and 48 functions of 34–35 46–47 49–50 68 production of 46 – 47 treatment with 47 142 143 163–164 Insulin resistance 4 49 66 70 Isocaloric diet 62 Jenkins David 113–116 Jogging 39 41 42 – 43 Jordan Michael 16 – 17 Juices 165 Juvenile onset diabetes. See Diabetes type 1 Ketogenic diets 58 63 – 64 Kidney disease/failure 25 44 –45 141–142 143 Kilocalorie 104 Krebs Hans 52 Latino/Hispanic Americans 24 LEARN diet 67 Learning 102–103 Leptin 50 – 51 Lifestyle modification cognitive function and 102–103 commitment to 5 154–155 158 need for 67 77 96 154 Lifschitz Mervyn 48 Lipolysis 35

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Low-carbohydrate diets 57–58 63–64 66 68–69 Low-fat diets 22–23 56–58 88. See also High-carbohydrate diets Low-intensity exercise 39 Ludwig David 66 Lunch sample 153 Macronutrients 53 Ma huang 94 Meal planning 106–110 128–129 153 Meals interval between 163 Meats 119 126 Medications. See also specific drugs absorption-modulating 32–33 93 adjustments of when dieting 122 insulin reduction 164 insulin treatment 47 142 143 163–164 for prediabetes 96–97 for weight control 51–52 53 92–95 Mediterranean diet 22 58 117 Men 24 40 87 Meridia sibutramine 92–93 Metformin 96 Middle-aged adults 24 36–37 Mineral supplements 121 Mitochondria 53 Monosaccharides 112 Monounsaturated fats 117 Muscle mass body mass index and 16–17 Nerve damage 25 Neurotransmitters 51 Non-exercise-associated thermogenesis NEAT 29 Nutrient claims 125 Nutritional recommendations 21–23 88. See also Draznin Calorie Nuts 127 Obesity attitudes toward 81–83 case studies 145–149 causes of 20–23 diabetes and 15 23–26 health risks of 15 23–24 25 measurements of 14–17 Index 175 prevalence of v 17 – 20 risk of death and 19 treatment of. See Weight loss upper- vs. lower-body 17 O’Neal Shaquille 17 Orlistat 32 33 92 93 Ornish diet 64–65 66 67

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Patience 60 Pedometers 160 Personal commitment 5 154–155 158 Phentermine 51 94 Physical activity. See Exercise Physicians role of 4 5 76 – 79 selection of 85–86 157 Pioglitazone 96 Polyunsaturated fats 116–117 Pork cuts 126 Portion sizes 108 111–112 Poultry 126 Prediabetes 96–97 150–151 Primary care physicians 78 – 79 Procedural learning 102–103 Protein metabolism 49–50 53 54 Proteins dietary 54 Race diabetes risk and 24 Resources 167 169–170 Restaurant dining 108 119–120 129 Resting energy expenditure. See Basal metabolic rate Restraint dietary 89 Retinopathy diabetic 25–26 44 141 143 Risk of death. See Death risk of Rosiglitazone 96 Roux-en-Y surgery 95 Saint-John’s-Wort 94 Satiety 50 51 Satiety center 51 Saturated fats 116–117 Sedentary lifestyles 21 Self-directed programs 86 Serotonin 51 Serving sizes 108 111–112 Sibutramine 92 – 93

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341 Index Snacks 127–128 153 Soy products 127 Stationary bikes 43 Stress test 44 Sugar blood. See Blood-sugar levels Glucose Sugar Busters diet 63 Sugars dietary 112–113 123–124 Supplements 120–122 Surgery bariatric 86 95–96 Swimming 43 Teenagers. See Children and adolescents Thermic effect TE 29 Tofu 127 Treadmills 42 160 Type 1 diabetes. See Diabetes type 1 Type 2 diabetes. See Diabetes type 2 Unsaturated fats 116–117 Very low-density lipoproteins VLDLs 64 Vitamins 120–122 Voluntary energy expenditure. See Activity thermogenesis Waist circumference 17 Walking 40–42 159–160 Weight hormonal regulation of 49–50 Weight ideal 14 – 15 Weight gain anxiety and 160–161 Weight loss. See also Draznin Plan attitude modifications and 81 – 82 caloric intake recommendation for 87 diet and exercise combined for 4–5 67 68–69 71 difficulty of 82 – 84 eating behavior modification 87 – 89 energy balance and 28–31 55 61 energy value of foods and 89 – 92 exercise routine for 87. See also Draznin Mile goal setting 84 99–100 157 individualized care for 5 72 – 79 maintenance of 4–5 99 100–101 medications for 32–33 51–52 53 92 – 96 mental and emotional readiness for 85 physician selection 85–86 157 plateaus in 98–99 165 realistic expectations for 84 – 85 seven steps of 82 Weight Watchers diet 66 Women 24 40 87 Worldwatch Institute 17 Wyatt Holly 100

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342 Index Xenical orlistat 32 33 92 93 Yudkin J. 21 – 22 Zone diet 63 65 66 67

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