Am I Insulin Resistant?

In my last post, I discussed Metformin and how it lowers insulin levels.  So how do you know if you are insulin resistant and have high insulin levels?  There are signs, symptoms, and laboratory results that can tell you.

The symptom that I see the most is pronounced carbohydrate cravings.  Because of hormonal changes that occur naturally as we approach the peri-menopause and menopause years, there is a natural pre-disposition to insulin resistance.  This is true of men in the same age range also.  The typical scenario I see is a middle aged patient who has difficulty losing weight and craves carbs like never before.  All of their weight gain seems to be in their mid section.

The sign that I see the most is called acanthosis nigricans.  It is a darkening of the skin in the crease on that back of the neck, and/or in the armpits and groin.  It is quite common to also see the development of skin tags in association with this.  In younger women who are still in their menstruating years, the development of acanthosis nigricans, skin tags, abnormal facial hair growth, and abnormal menses indicates that they have PCOS.  This is a syndrome that causes insulin resistance.

Another sign that is almost universally present with insulin resistance is the deposition of new abdominal fat.  Patients will tell me that this is where they gain their weight first.  This finding indicates an absolute health disaster waiting to happen.  If this is taking place in you, you should immediately initiate a low carbohydrate diet, and consider adding phentermine and metformin to assist you in your efforts to lose abdominal fat.

There are some lab tests that can assist in the diagnosis of insulin resistance.  At the office, I order these sometimes.  Often, all I need to diagnose insulin resistance is the signs and symptoms.  If I need to get labs, there are four tests that can be ordered: Hemoglobin A1c, Fasting Blood Sugar, Oral Glucose Tolerance Test, and NMR Lipoprofile.  All of our providers are skilled in determining whether or not patients need any of these tests, and we can make the appropriate recommendations to you.

In sum:  if you are a middle age person and you are experiencing increased carb cravings, weight gain in your midsection, and possibly acanthonsis nigricans, then we should discuss insulin resistance at your next visit.  You will need to begin restricting carb intake.  Labs may need to be ordered and the addition of Metformin to your medication regimen could be very helpful.  

Wickham

Can Medicine Lower Your Insulin Level?

As promised, I stated in my last post that I would shed some light on a medicine that lowers your insulin level.  As you might recall, high insulin levels lead to storage of body fat resulting in an increased body fat mass.  Excess body fat leads to disease - regardless of your weight or your BMI.  You can be of "normal weight and BMI" but have a high body fat percentage and this puts you at risk for type two diabetes, abnormal lipid panels, high blood pressure, vascular disease, etc.

This is the reason that I put so much emphasis on restraint when it comes to carbohydrate intake.  At the same time, I constantly emphasize getting the correct amount of protein in your diet, and I emphasize the fact that the consumption of most dietary fats is not the enemy.  The idea is this: carbohydrates can cause large increases in insulin, and protein and fat do not.  So, that covers the diet side of things.  Is there a medicine that helps bring down insulin levels?  The answer is yes.

Metformin is a medicine that has been on the market for about 50 years.  It is a medicine that is used to keep pre-diabeties (know as insulin resistance) from advancing to diabetes.  It works by making cell membranes more sensitive to insulin so that insulin passes easily from the serum to the inside of the cell - this lowers serum insulin levels.  It is this effect that aids in weight loss from decreasing body fat.  Think of it this way - a lower insulin level lowers the "fat storing signal" to your body.  In the presence of a carbohydrate restricted diet, the "fat burning signal" acts unopposed.  

Metformin can be used in conjunction with phentermine.  The major contra-indication is renal insufficiency or renal failure.  Most of my patients do not have this.  The major side effect is GI upset if you take it on an empty stomach - so take it after the biggest meal of the day.  It is cheap and we stock it at my practice.  The cost for a months supply is between $10 and $15 depending on the dose.

My next post will discuss how to know if you have insulin resistance, and therefore need a drug like metformin.  Don't forget - know your lean mass and fat mass with precision; have your Inbody 770 test performed in March - its only $20.

Dr. Simonds

Things That Go Together

There are some reasons why I teach diet the way I do.  In short, there are some things that often occur together and lead to weight gain from body fat, and some things that occur together that lead to weight loss from body fat.

The Triad of Body Fat Gain
1. Excess carbohydrate intake - particularly sugar, flour, and starch which leads to #2.
2. High insulin levels - this is the recipe for weight gain from fat and the induction of many diseases.
3. Lack of physical activity - this includes both planned exercise and just being more active in your activities of daily living (less sitting and more moving).

The Triad of Body Fat Loss
1. Decreased carbohydrate intake - removing sugar, flour, starch and replacing them with protein and fat.  This leads to elevated metabolic rate, and increased sense of satiety - more importantly it leads to #2.
2. Low insulin levels - this is the recipe for weight loss from decreasing body fat.  It also corrects disease states like type two diabetes.
3. Increased physical activity - I think you get the concept.

If you want to track your lean and fat mass closely to see how they are responding to your diet and exercise regimen, then you need to do the InBody 770 body composition analysis test.  During the month of March it is only $20!  Call the office to schedule the test.

Stay tuned - my next post will be about an inexpensive medicine that lowers insulin levels leading to greater fat mass loss.  It pairs will with phentermine and can increase your rate of weight loss.


Dr. Simonds

What Is Your Body Composition?

For those of you who know me, you have probably heard me talk about body fat.  You see, having a high body weight isn't a risk factor for disease - No, it's having a high body fat percentage that puts you at risk.  Your weight isn't the issue, your body fat percentage is.  Furthermore, excess fat accumulation in your abdomen (visceral fat) is an absolute recipe for disaster!  I don't care if you are a "normal" weight or are overweight - if you have too much body fat it is bad.

This is why I am so particular about teaching diet - the composition of your diet is of utmost importance.  If you have excess body fat (and you intend to reduce it) the bottom line on diet is this:

1. Its going to make you sick with diseases like diabetes, etc.
2. To stop the accumulation of fat, and to signal your body to burn fat,  you must restrict carbohydrate intake.
3. You must eat more fat and more protein at the expense of carbohydrate.

These are principles that I teach day in and day out - I never quit talking about it.

So, with all of this in mind, I would like to tell you about the InBody 770.  This is a device that I have in my Durham office that can give you a precise, detailed body composition analysis.  It will tell you exactly how much lean mass and fat mass your body has and how it is distributed.  It is a great way assess where you stand as far as your body composition, and to assess how your diet and exercise efforts are impacting your fat mass loss.  

If you would like to have the InBody 770 test performed, you can call the Durham office to set up a time - the phone number is 919.490.8899.  The cost is normally $40, but in the month of March it is only $20.  

I look forward to seeing you soon.

Wickham

My Practice of Obesity Medicine

At the beginning of 2015, I thought I might share some thoughts about where my Obesity Medicine practice is. 

First, you have to realize that I myself have undergone a transformation of sorts.  I began treating overweight and obese patients ten years ago in 2004.  At the time, I was practicing Emergency Medicine full time.  Emergency Medicine is the field of my residency training and first board certification.  So, in 2004 I considered myself an ER Doc who practices “weight loss” on the side.  Well, things changed.  My practice grew and eventually I stopped the ER altogether by January of 2008.   I began attending conferences that kept me up to date on the rapidly advancing science of obesity.  Through this process, I became board certified in Obesity Medicine in 2012.  I now have two board certifications: Obesity Medicine and Emergency Medicine.  Now, ten years later, I am an Obesity Medicine Specialist who used to practice Emergency Medicine.

My practice used to be described as “weight loss”, but now it is better characterized as the treatment of a complex medical condition known as obesity.  You see, weight (and by extension BMI) is just one parameter that can be used to evaluate obesity.  The truth is that obesity is a disease of excess body fat, and the body fat is usually behaving in a diseased manner.  Think of it like this – your body fat is an organ that can enlarge itself and become dysfunctional (this has been well described by Dr. Harold Bays and the term he uses for it is “adiposapathy”).  You may, or may not be, overweight.  It’s about the amount of body fat you have, the distribution of the body fat, and how the fat is functioning biochemically.  So, it is possible to have a “correct weight” and have the disease of obesity or be “overweight” and not have the disease of obesity. 

The problem with this condition of “adiposapathy” is that it eventually manifests itself in multiple organ systems causing numerous health problems.  Some of those health problems include (this is only a partial list) : lipid abnormalities, type two diabetes, high blood pressure, vascular disease, fatty liver disease, and multiple different inflammatory conditions.  In other words, it creates a “toxic metabolic stew” that will take you to the grave early.  My job as an Obesity Medicine Specialist is to treat patient’s body fat mass.  When I do this, the risk of developing these multiple medical problems drops profoundly.  If a patient already has some or all of these medical problems, and I can reduce their body fat, the patient’s medical problems immediately began to correct themselves.  Bottom line – treating the condition of obesity results in better health and longer life.  It is a form of “Ultra Prevention.”  Once patients have lost a significant amount of body mass, my goal is to prevent the regain of body fat.

So what is my treatment approach to patients with excess body fat or a patient who has lost body fat and is trying to prevent fat regain?  The first and most powerful tool is diet.  The teaching method I use is based on 5 important principles:

1.     Protein Is Primary. It is the foundation to your diet success. The key is to eat the correct type and amount of protein at the right time intervals. The providers at Doctor Simonds Weight Loss will make a specific recommendation to you about your total daily protein needs. Most patients will need between 90 and 150 grams of protein daily while dieting. Getting this correct amount of protein will spare your lean muscle mass while losing weight, and force your body to burn its own fat for energy. More importantly, consuming 30-40 grams of protein in one meal raises your metabolic rate by 40% for 3-4 hours after you do this. This is the same as running 30 minutes on a treadmill. Less than 30 grams will not evoke this response. The best protein source to produce this change is protein from a milk source like whey or calcium caseinate. Protein from eggs, meats (poultry, red meat, and pork) and fish are acceptable also. Vegetable protein lacks the amino acid composition to produce this effect. If you don’t eat a large portion of carbohydrates (carbs) with it, your body will get the extra 40% of energy it requires by burning abdominal fat stores – in other words, it slims your waistline and who doesn’t want that?

2.     Fat is Filling and It Doesn’t Make You Fat. The fullness, or satiety, that fat produces helps you feel satisfied with much smaller amounts of food. In addition, in the absence of carbs, fat serves as a great energy source, raises good cholesterol (HDL) and lowers your triglycerides (free floating fat in your blood). In the absence of high insulin levels (which come from eating carbs), your body’s physiologic response to fat is to burn it – not store it.

3.     Carbs Make You Crave, and They Make You Fat. Flour, sugar, rice, and potatoes, in most of their forms, are absorbed quickly by your GI tract. This causes a surge in insulin levels. Elevated insulin levels promote fat storage – particularly in your abdomen. Elevated insulin levels will produce other evils: increased hunger, increased cravings, lower metabolic rate, high blood pressure, cholesterol abnormalities, and blood sugar abnormalities.

4.     Portions Are Powerful. I have already hinted that to lose weight you have to reduce quantity/calories. The goal is to get the content of the food you are eating correct, so that you can eat smaller portions and be satisfied with that. If prescription medications are needed to reduce appetite and help with this, we can provide them. Many people do well keeping track of their food intake using an app such as My Fitness Pal, which can help ensure you are consuming the proper amount of protein each day and can also keep you accountable on your calorie and carbohydrate intake.

5.     Timing Is Tantamount. One of the common problems I see is patients skipping meals, eating one meal per day, etc. This creates a host of problems. My recommendation is to get at least 3 “servings of protein” (30 - 40 grams each) spaced out 3-4 hours apart. By doing this, and limiting carb intake, you will find that your weight loss will be greater, your satiety (feeling of fullness) will be improved, your metabolism will work better, you will lose more body fat, and you will be happier with the entire “diet experience.”

The second tool I use is medication.  I use multiple medications and combinations of medicines to achieve the treatment goal of fat loss or prevention of fat regain.  Some of the medicines I regularly use are phentermine, diethylpropion, phendimetrazine, metformin, topiramate, bleviq, contrave, and numerous others. Each patient is different so it is my goal to tailor a medication approach that works for you. 

The third tool I use to decrease body fat and enhance health is physical activity.  So, in summary, obesity is a complex disease characterized by excess, dysfunctional body fat.  It is my goal to help patients lose this fat, and then keep it off.  To achieve this, I use a specific diet approach that encourages protein and fat, limits carbohydrates, and encourages proper portion sizes, and the correct timing of eating.  I pair this with medications if needed, and encourage patients to be physically active.  For those of you who are active patients, I say “thank you” and keep up the war on obesity.  For those of you who have “fallen off the wagon”, I am here to help and encourage you.  I will never be judgmental.  If it was easy to be thin, we would all be thin – I know it is hard and I am here to assist.  If you are not a patient yet, I encourage you to get serious about this disease if you have it.  I am here to help you.

Dr. Simonds

Cycle 2 Over - The Tube is Out

Alright everybody, here is the deal - my weight before the start of the basketball game was 230.4.  I removed the tube.  So in 10 days I went from 242.6 to 230.4 - a total of 12.2 pounds.  I started my first cycle of the KE Diet on February 15th at 260.4.  In 29 days I lost a total of 30 pounds even!  Now I have to transition into ongoing weight loss, and I really feel the KE experience has prepared me for this.

Tomorrow is the last day to register for the free KE Diet giveaway.  Don't forget to register. The details can be found at www.paweightloss.com.

Wickham

Starting Day 9 of KE - One Day to Go

Hello all, sorry for the absence of a blog yesterday - I got very busy and just didn't have a chance to do it.  Two more patients started the KE Diet yesterday, and that amongst other things kept me busy.  So, it is now Saturday morning and tomorrow the tube is coming out!  My weight this morning is 232.2.  I'm holding out hope that I can make 230 by tomorrow when the tube comes out.  Please stay tuned for my final update tomorrow, but I won't stop blogging after that.  I am on a journey to get my body weight and my body fat down and the KE Diet is part of this process, but my lifestyle changes are also part of the process, and I don't want you to miss out on that part.

My patient Cathy Gebhart is doing great.  I spoke with her yesterday, and she is still in ketosis and still losing weight.  She had the Nutritional Smart Tube removed Wednesday.  She is remaining disciplined and motivated and she feels great.  I had a chance to meet her husband and he is doing a great job of supporting her.  I will be following up on her twice weekly to make sure she stays on track.  Cathy is a great example of someone who is ready to do the KE Diet.  She is extremely motivated, she is committed to the idea of adopting a low carb lifestyle, she did not mind incorporating the Nutritional Smart Tube into her life, and she did not have a bunch of excuses.  Excuses you say?  That's right!  No making excuses for why the tube wouldn't work with her lifestyle, no excuses for why she couldn't break the love affair with carbs, and no excuses for why she can't make make weight loss and lifestyle changes the number one priority in her life right now.

If you think you have the same "No Excuse Mentality" that Cathy has, then I think you are ready for the KE Diet.  This is the biggest step - deciding if you are ready.  If you think you are, then I want to talk with you. Please let me or the office staff know, and I will take it from there.  Monday, March 17th at 7pm is the drawing for a free KE Diet Treatment.  Don't forget to register.  

Wickham