Losing Weight with Your Diabetes Medication

Foreword by Joe Prendergast

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Losing weight can make managing your diabetes easier while preventing and improving-even possibly reversing-common diabetes-related complications.Countless people with diabetes face the challenge of controlling their weight while successfully managing their medical condition-because many diabetes drugs actually promote weight gain. In the first-ever investigation of its kind, Losing Weight with Your Diabetes Medication clearly lays out everything you need to know about your treatment options and how they affect your weight, as well as a 360-degree analysis of cutting-edge new drugs like Byetta that are revolutionizing diabetes care. One of North America's leading diabetes journalists and patient-advocates, David Mendosa provides this information alongside everything you need to know to manage your weight and your health, including: An A-to-Z rundown of dozens of diabetes drugs and how they affect your weight Other weight-loss drugs that can directly improve your diabetes management Overview of Byetta and other revolutionary GLP-1 drugs and how they work best for you Tips for incorporating exercise into each day without changing your schedule Choosing the most nutritious, low-glycemic index foods to maximize weight loss In-depth resources and prescribing information Losing Weight with Your Diabetes Medication is an essential and inspirational breakthrough for diabetes patients who want to take control over their condition, end the cycle of ineffective diets, and finally shed unwanted weight.

The Marlowe Diabetes Library

Good control is in your hands.

Since 1999, Marlowe & Company has established itself as the nation's leading independent publisher of books on diabetes. Now, the Marlowe Diabetes Library, launched in 2007, comprises an ever-expanding list of books on how to thrive while living with diabetes or prediabetes. Authors include world-renowned authorities on diabetes and the glycemic index, medical doctors and research scientists, certified diabetes educators, registered dietitians and other professional clinicians, as well as individuals living and thriving with prediabetes, type 1 or type 2 diabetes. See page 212 for the complete list of Marlowe Diabetes Library titles.

About the Author

DAVID MENDOSA is a freelance journalist and consultant specializing in diabetes. A coauthor of The New Glucose Revolution: What Makes My Blood Glucose Go Up . . . And Down?, his articles and columns have appeared in many of the major diabetes magazines and Web sites. He lives in Boulder, Colorado.

Also by David Mendosa

The New Glucose Revolution: What Makes
My Blood Glucose Go Up . . . And Down?
(with Jennie Brand-Miller, PhD,
and Kaye Foster-Powell)

I gratefully dedicate this book to John Dodson
and to Dr. John Eng.

John was a major inspiration for me to
start taking Byetta in the first place and he
has become one of my best friends.
Dr. Eng discovered the drug that became Byetta.
These men are my heroes.

Foreword

By J. Joseph Prendergast, MD

David Mendosa has written an excellent book on Losing Weight with Your Diabetes Medication: How Byetta and Other Drugs Can Help You Lose More Weight Than You Ever Thought Possible. This is real-time knowledge about drugs that are revolutionizing diabetes care.

When you first learn that you have diabetes, it is very frightening. A family history might have warned you. You might bring a friend to help absorb the medical advice and treatment plan. You will realize that you face a lifetime vigil, and you will feel that complications are inevitable.

Your doctor will provide technical information tailored to your immediate informational needs. An educational process based on those needs begins.

When you feel comfortable with your level of knowledge, you might look for other mentors, both academic and clinical. Technical information can benefit from real-life common sense. Often, there will be a talented person who will add greatly to your understanding because that person has lived through your experience. Often, this person will be very good at explaining the fine points about diabetes. It might be a writer or a reporter, who can explain all aspects of diabetes care and help you through your life's course. One such person is David Mendosa.

And now we have Byetta and will soon have other drugs in the same class. These are "gut hormones" that mimic how glucagonlike peptide-1 (GLP-1) works. They are given by shot that has been modified to last long enough to enable your pancreas to grow many metabolic cells and, in some people, even to grow insulin-producing beta cells.

David Mendosa explains it well. Byetta is the best new example of why doctors must listen to their patients more than to pharmaceutical marketing and recognize the great potential of new medications. Beta cells that have become prematurely dysfunctional and die prematurely begin to grow back in many people. New "metabolic cells" producing hormones never before known to exist in the company of beta cells may contribute greatly to weight loss. This is very important! There is so much new to learn.

Training of medical professionals in medical school changes over time. Researchers know that learned knowledge must adapt to the power of new observations, as well as information from a patient. The concept of listening to the patient has been the basic tenet of good medical care for as long as I have practiced medicine.

There is a new phenomenon in health care today. Patients are better educated about their medical problems. The Internet has spawned patients' need to know all aspects of their disorder. Doctors today are not surprised by their patients' depth of knowledge about their disease and the range of available treatments.

This has given rise to a new system where the doctors, nurses, medical assistants, and writer/reporters (professionals) need the information of day-to-day observations and conclusions that only patients (amateurs) can provide. This coupling of professional knowledge with the power of patients' important observations is what is called the Professional-Amateur (Pro-Am) joint approach to diabetes care. I first heard this term while reading The Long Tail by Chris Anderson, editor in chief of Wired magazine. Chris Anderson's business book outlines how this Pro-Am concept is changing every aspect of society, not just diabetes. It is more important today because Byetta has turned diabetes physiology upside down.

David Mendosa's book provides a practical guide to this Pro-Am approach with Byetta. He displays in this book professional and personal experience in the field of diabetes. He has contributed regularly to the field of diabetes care for patients and physicians. This book contributes more.

The book is well buttressed by experience and scientific end notes. Personal interviews with scientists provide key perspectives and information. Mendosa is educating us all about disease and the best treatment.

Mendosa's book explains clearly how these drugs work. He addresses the most important side effect, weight loss. Diets generated by many health professionals have failed to work over time. Though control of food intake is important, a new approach is required.

Weight gain often happens in three stages in those with diabetes. Initially, there is subtle excessive eating. This changes to a subtle increased drive to eat, and ends in out-of-control eating driven by intracellular metabolic changes. This is a phenomenon of diabetes that is often misunderstood. The sequence is powerfully triggered by the insulin resistance of type 2 diabetes. The abnormal intracellular metabolism then contributes to profound fatigue that seems to worsen despite apparent success of conventional therapy.

Insulin resistance can bring on a fear in many patients of diminishing physical capacity or approaching death. Byetta has been important in reversing these symptoms. These patients have a metabolism so totally out of control that it cannot be regulated by conventional therapy. Byetta provides a new powerful treatment we've not had before. No simple nostrum, Byetta. This is metabolic power at its best.

Good control can often mean weight gain. Weight gain seemed to be a certainty of strict control. This is unfair. Often, patients have a technical victory but physically still feel the same. No wonder patients experience a deep frustration.

In chapter 7, Mendosa provides a clear discussion of the role of insulin resistance and in beta cell dysfunction in diabetes and how the Byetta works within these two elements. He gives a good explanation of why aftermeal glucose testing is becoming so important that it may make the A1C disappear from diabetes assessment in the near future. David is ahead of his time.

Mendosa includes an important discussion of the variation of the effect of Byetta in different individuals. This is important for the Pro-Am team to know. He has excellent end notes, just as we would expect from any scholar.

Problems with Byetta are explored. But as Mendosa points out, it would be a shame to give up such a spectacular medication, when most can get a good result with coaching, medication adjustment, determination, and dedication. This is excellent practical advice.

When Byetta fails, it frustrates both the patient and the physician. Deft probing can usually solve the mystery of what allows some people to have spectacular success in their expected parameters while others have only limited success. David reveals his own personal success at overcoming his "plateau."

Mendosa includes the story of the life and times of my Byetta hero, John Dodson. He had personal success at weight loss, reversed his type 2 diabetes, and then completed his quest to get his life back after the death of his wife. Many people have had similar experiences in one form or another. I have learned from all of them.

It is easy to recommend a professional work by someone I so admire. This is an excellent book. I learned a great deal from David's observations. This will benefit my patients with diabetes and enable them to experience the tough spots on their way to success with Byetta. I'm so pleased to be a member of his Pro-Am team. As I have been often heard to say, David, "It's your time."

J. Joseph Prendergast, MD, FACP, FACE
President, Endocrine Metabolic Medical Center
President, Endocrine Therapeutics
President, Pacific Medical Research Foundation
Palo Alto, CA 94306

Introduction

It's easy to lose weight. I've done it hundreds of times. Mark Twain said that about smoking, but he might as well have been talking about losing weight.

Almost everyone who has type 2 diabetes knows about the old weight-loss diets and drugs. Until now, none of them helped us for more than a year or so. Yo-yo dieting even worsens our health. But now we have new drugs for diabetes that help us in new ways, such as making us feel full with less food.

I learned that I had type 2 diabetes in February 1994, when I went to the VA Clinic in Santa Barbara, California, for a pain in my side. After giving me a blood test, a doctor there asked me, "Has anybody ever told you that you have diabetes?" Nobody had even hinted that I might have diabetes. I didn't know the first thing about it. Nobody in my family had diabetes, and I had never met anyone who told me they had it.

MY DIABETES DIAGNOSIS DECISIONS

The diagnosis of diabetes is scary for many people. These people get obsessed with a fear of complications. Other people deny the diagnosis. They act as if they never heard of it. My reaction to my diagnosis of diabetes was different. I was determined to learn everything I could about it. This middle way comes naturally to me because of what I do for a living. I write.

At the time, I wrote for and was an editor of a business magazine. Every time I wrote or edited an article I had to learn something new. It's only news when it's something that you and your readers didn't know before. Learning about diabetes quickly became even more interesting to me than learning about business. As I learned more about diabetes I naturally wanted to share what I learned. Soon, I stopped writing about business so I could write only about diabetes. In 1995, I began to write for diabetes magazines, starting with a review in Diabetes Interview about what was then a little-known book about the glycemic index that was then only available in Australia. I also began to write articles on the Web, including my own Web site, www.mendosa.com. For the past few years I have written twice-weekly articles about diabetes at www.healthcentral.com/diabetes/c/17. This is my second book dealing with diabetes. Along with Prof. Jennie Brand-Miller and Kaye Foster-Powell, I wrote The New Glucose Revolution: What Makes My Blood Glucose Go Up . . . And Down? (2nd edition, Marlowe & Company, 2006). (Note: Terms in boldface are defined in the glossary at the end of this book.)

EXERCISING MY FINGERS

Because I am a writer, I spend most of my working hours sitting at a desk in front of a computer monitor. Besides typing as fast as I can, I exercise only my fingers when I work. I was never much of an athlete. My greatest athletic accomplishment came more than a decade before my diabetes diagnosis, when I finished a 10-kilometer race—in the next-to-last position.

Being a writer is an easy life. My life was so easy that I put on more than a few pounds. My lack of exercise and the presence of extra pounds almost certainly had something to do with my diabetes, even if those things didn't directly cause it. So, after the doctor told me that I have diabetes, my first order of business was to take long walks and to begin to lose weight. That worked for a while, but eventually my weight crept up again as I started eating more and stopped taking exercise so seriously.

I HAD TO CHANGE SIZE

After a dozen years with diabetes, I knew I had to make a change. Technically speaking, I was "morbidly obese." My weight may not have been killing me, but it was certainly crippling me. I'm tall—6 foot 2 ½ inches—but I tipped the scales at 312 pounds and had a body mass index (BMI) of 40. I was ashamed that I weighed so much. At the same time, I had almost given up hope that I could ever get down to a normal weight. I knew how to eat low-glycemic food, but I ate too much and exercised too little. A wall of fat separated me from my favorite pastimes. Ever since I was a little boy, I've loved to walk in the woods and hike in the highlands. Being close to the Rocky Mountains is one of the joys of living in Boulder. But a couple of years ago, my doctor told me that the pain in my left knee was arthritis. I could still walk where it was flat, but climbing or coming down hurt too much. Moving my big body became much harder. I had to use a grabber gadget to pick up the newspaper in the driveway. Getting out of an easy chair became more and more of a chore.

I first learned about Byetta more than 10 years ago, when it was still called exendin-4. In 2002, I wrote what I think was the first nontechnical article ever about Byetta. This was long before the U.S. Food and Drug Administration, in April 2005, authorized Amylin Pharmaceuticals and Eli Lilly to sell it in the United States.

By February 2006, I was desperate enough to consider taking Byetta myself. There can be negative side effects—especially nausea—but I was still curious. The FDA said that doctors could prescribe Byetta for people with type 2 diabetes who were using the most common drugs for controlling blood glucose—one of the sulfonylureas or metformin or both. (Since then the FDA has said that doctors can prescribe it with some other diabetes drugs, too.) I was taking both a sulfonylurea and metformin when I started on Byetta. My A1C level was a bit below 7.0 percent, which some—but not all—diabetes organizations consider adequate.

BYETTA'S POSITIVE SIDE EFFECT

My big interest was in Byetta's positive side effect—weight loss—and less in blood glucose control. But when I studied its prescribing information, I saw that the people in the clinical trials lost only an average of about 6 pounds after 30 weeks. I wasn't impressed. I later spoke with an endocrinologist, Dr. Joe Prendergast, whom I have admired and written about for years. When he told me about his patients' experiences, I was convinced to try it. Dr. Joe told me that the average weight loss for his 200 patients using Byetta was 35 pounds after nine months. How could his patients be so much more successful in losing weight than those in the clinical trials? I think it was because the people running the clinical trials told them not to change whatever they were doing. But Dr. Joe encouraged his patients to eat less and exercise more, which is precisely what I wanted to do.

I FOUND A DOCTOR

My regular doctor, who had been ragging on me for years to lose weight, didn't know about Byetta. When I asked him to prescribe it for me, he read the clinical trial results but decided I wouldn't lose much weight on it. So I became determined to find a different doctor, and my salvation came in the form of an e-mail from Jeffry N. Gerber, MD, who told me that he is a family doctor who specializes in encouraging his patients to lose weight. His office is south of Denver, almost an hour from my home in Boulder (but a lot closer than Dr. Joe, who practices in California). He wrote that he was eager to start some of his patients on Byetta.

Dr. Jeff wrote, "You can be the first, if you wish." I wished. I wanted better health and knew that my weight was my biggest obstacle. I got my wish for lower weight and better health. Byetta didn't cause me to lose weight. But it made losing weight easier. How? By cutting my appetite, so that I was seldom hungry anymore. I totally changed what and how much I ate. Byetta reduces appetite in two ways. It slows gastric emptying, and it also affects the central nervous system, triggering a feeling of satiety. Since I knew that about half of all people who take Byetta have nausea, I prepared for it by eating very little from the first. As a result, I've had almost no negative side effects. The only nausea I experienced was for about three hours when I took the first shot. Once I started injecting Byetta, I began to lose weight immediately. I soon noticed that my trousers and shirts were too loose. I enjoy friends telling me how much thinner I looked.

While lots of things in life are a vicious circle, Byetta and energy are a virtuous circle: The more weight I lost and the more I exercised, the more energy I had. All this feedback gave me more motivation than ever to keep on losing weight. I also noticed that I needed less and less food to fill my stomach as it got smaller.

Since starting on Byetta fewer than two years ago, my weight dropped from 312 to 181 pounds. From the start, I told everyone who would listen that my goal by October 26, 2007, was to weigh less than when the U.S. Army had honorably discharged me 50 years earlier. That meant weighing less than 195 pounds, which would also give me a BMI in the normal range. I have already passed that goal!

With my lower weight, my blood glucose level has come way down. My A1C went from 6.8 percent to 4.6 percent, despite my stopping the other diabetes drugs I was taking when I started Byetta. The arthritis that I had is totally gone. I can go for hikes in the highlands again. I also had elevated liver enzymes that showed I had a fatty liver, which can lead to nonalcoholic steatohepatitis and then to liver failure. Now, my liver enzymes are normal. My blood pressure was never all that high, but it, too, has come down. It has dropped from 140 over 80 to about 100 over 60. That's well below the "normal" level of under 120 over 80. All of my cholesterol levels are much better. My total cholesterol has dropped from 225 to 155, well within the normal range of under 200. My LDL cholesterol dropped from 158 to 93, below the recommended level of under 100. My HDL cholesterol—the good stuff—was always far too low. It has gone from 28 to 40, right at the recommended level. My triglycerides went from 193 to 109. That, too, is well within the normal range of up to 150. Now that my weight and blood glucose levels are under control, I feel at least 10 years younger. I have far more energy than I have had in years. Also, my mood is much more positive.

I am such a believer in the company that makes Byetta, Amylin Pharmaceuticals, that about the time I started taking Byetta I bought 100 shares of company's stock. I am still a believer. But I sold my shares later that year, so that what I write won't give even the appearance of a conflict of interest. Sharing what I have learned and experienced about Byetta and losing weight is a lot more important to me than any money I could make as an investor. I offer you this book as encouragement for you to improve your health by losing weight.

MY CLOTHES PROBLEM

The biggest problem is that my waist size dropped from 56 inches to 36 inches. That meant I had to buy a whole new wardrobe of slacks, shirts, and underwear, as well as having my ring and watchband resized. At least the size of my feet didn't change! And since my head is still as big as ever, I didn't have to buy any new hats. It turns out that having clothes get too big is a problem I share with lots of people. The launch of Byetta has been so successful that already more than half a million people take it.

PROFILE
JOHN MORTENSEN REDUCED HIS A1C

"I think I am pretty typical guy with type 2 diabetes," John Mortensen says. He's a 41-year-old man who got his diabetes diagnosis in his late twenties and has used various medications over the years with differing degrees of success. He says that eight months ago, after a really bad year, his A1C was 9.2. Then, his endocrinologist put him on Byetta. "My blood glucose immediately dropped to where I felt a little light-headed occasionally," he says. While he suffered some of the typical early Byetta side effects such as tummy issues, after a couple of weeks, things leveled out and he began to feel much better. "Then, after three months on the spit, I had lost a good amount of weight, and my A1C was down to an amazing 5.9!"

After some experimentation with Byetta, John says that he has found what works for him. "Basically, I stick to eating around 150 grams of carbs a day," he says. "I think this forces me to choose better foods.

"Byetta's appetite suppression does work for me," John says. "I am rarely hungry. So, now that I am seven months into my Byetta, I have lost more than 60 pounds and am just 20 or so pounds away from a perfect BMI." His latest A1C is an outstanding 5.1. "This stuff changed my life," John exclaims.

My diabetes is under control. It may not be cured, but it certainly is in remission. Now, one problem that I don't have to carry is the invidious label "obese" or "overweight." When I reached my original goal of having a normal BMI, I began to look ahead. The Harvard Nurses' Health Study showed that a BMI of 23 or below is even healthier, and I have recalibrated my goal to that level. On my frame, that means weighing 181. That's exactly what I weigh as this book goes to press. Having cycled down from "morbidly obese" through "obese," I want a label to describe the new me. We don't have a formal one for it. But about a year ago, I read about a businessman who cares as much about diet and nutrition as making money. The writer described him in a word that stuck in my mind and hope someday people will use when they think of me. That word is trim.

DIABETES AND WEIGHT

Why Diabetes Doesn't Make You Fat

The numbers just don't add up. More than one-third of all American adults are overweight. Plus, nearly one-third of us are obese. Many people think that being heavy causes diabetes. But since a lot more people are overweight or obese than have diabetes, weight can't be its cause. Government data show that 34.1 percent of adults are overweight. These people have a body mass index of 25 to 29.9. Another 32.2 percent are obese, meaning a body mass index of more than 30. Together, almost exactly two-thirds of us are carrying more weight around than is good for our health.

The body mass index, or BMI, is a new term to many people. However, it is the measurement of choice for many physicians and researchers studying weight. BMI uses a formula that takes into account both a person's height and weight. It works well for just about everyone except for children or bodybuilders and others who are unusually muscular. Web sites like nhlbisupport.com/bmi/ make it easy to figure out your BMI, but you can also calculate it without a computer. Here's one way:

Multiply your weight in pounds by 703.
Divide that answer by your height in inches.
Divide that answer by your height in inches again.

The body mass index isn't perfect. It is a quick and dirty tool that any of us and our doctors can easily and inexpensively use. But it doesn't predict body fat with complete accuracy. That's not the point. The point is that a high BMI is an estimate of body fat measured indirectly. The estimate isn't too good for three groups. For children we need to use a different formula. And for muscular athletes the BMI can lump them into the overweight or obese categories even though most of their extra weight is lean muscle, not fat. Also, some people who score in the healthy BMI area may have a high percentage of body fat and therefore a slightly higher health risk. Nonetheless, if you are an adult who is not particularly athletic, a high BMI needs to be a call to action.

By comparison to the two-thirds of Americans who are overweight or obese with a body mass index of 25 or more, 7 percent of us have diabetes. So being heavy can't be the cause of diabetes. Even when we consider the one-fourth of Americans with prediabetes, there's got to be more to causing diabetes than being well upholstered. Some of the usual suspects include genes and lack of exercise.

YOUR LINK BETWEEN DIABETES AND WEIGHT

Still, more than 85 percent of people with diabetes are overweight or obese. That means there must be some connection between diabetes and weight. While being overweight can't be the cause of diabetes, weight and diabetes are linked. They probably have a common cause. This strong correlation is why you will often see type 2 diabetes described as a "lifestyle disease." This implies that diabetes results from a choice, just as other lifestyle choices like cigarette smoking and heavy alcohol consumption lead to other diseases. It's blame-the-victim time.

Even the government's Centers for Disease Control and Prevention (CDC) buys into this argument. "We know obesity causes about two-thirds of diabetes," the agency told state health agencies in 2005. In fact, no one has ever demonstrated that obesity causes diabetes or even insulin resistance

Genre:

On Sale: Feb 26, 2008
Page Count: 240 pages
Publisher: Da Capo Lifelong Books
ISBN-13: 9780738215037

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David Mendosa

About the Author

David Mendosa is a freelance journalist and consultant specializing in diabetes and a coauthor of The New Glucose Revolution What Makes My Blood Glucose Go Up . . . And Down?. Having lived with type 2 diabetes for over ten years, he has successfully lost more than 100 pounds since starting Byetta in 2006. He lives in Boulder, Colorado.

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