Erectile dysfunction
COMUNITY-BASED POPULATION studies of males aged 39–70 years found that the prevalence of impotence ranges between 10 and 50 percent. Diabetes is a key risk factor, increasing the risk of erectile dysfunction more than threefold and afflicting patients at a younger age than usual. Poor blood circulation in diabetics is the likely reason for this increased risk. The risk of erectile dysfunction also increases with age and severity of insulin resistance, with an estimated 50–60 percent of diabetic men above the age of 50 having this problem.25
Polycystic ovarian syndrome
AN IMBALANCE OF the hormones can cause some women to develop cysts (benign masses) on the ovaries. This condition, called polycystic ovarian syndrome (PCOS), is characterized by irregular menstrual cycles, evidence of excessive testosterone, and the presence of cysts (usually detected by ultrasound). PCOS patients share many of the same characteristics as type 2 diabetics, including obesity, high blood pressure, high cholesterol, and insulin resistance. PCOS is caused by elevated insulin resistance26 and increases the risk of developing type 2 diabetes three-to fivefold in young women.
TREAT THE CAUSE, NOT THE SYMPTOMS
WHEREAS MOST DISEASES are limited to a single organ system, diabetes affects every organ in multiple ways. As a result, it is the leading cause of blindness. It is the leading cause of kidney failure. It is the leading cause of heart disease. It is the leading cause of stroke. It is the leading cause of amputations. It is the leading cause of dementia. It is the leading cause of infertility. It is the leading cause of nerve damage.
But the perplexing question is why these problems are getting worse, not better, even centuries after the disease was first described. As our understanding of diabetes increases, we expect that complications should decrease. But they don’t. If the situation is getting worse, then the only logical explanation is that our understanding and treatment of type 2 diabetes is fundamentally flawed.
We focus obsessively on lowering blood glucose. But high blood glucose is only the symptom, not the cause. The root cause of the hyperglycemia in type 2 diabetes is high insulin resistance. Until we address that root cause, insulin resistance, the epidemic of type 2 diabetes and all of its associated complications will continue to get worse.
We need to start again. What causes type 2 diabetes? What causes insulin resistance and how can we reverse it? Obviously, obesity plays a large role. We must begin with the aetiology of obesity.
SIMON
When he came to the Intensive Dietary Management (IDM) program, Simon, 66, weighed 267 pounds, with a waist circumference of 135 cm and a BMI of 43. He had been diagnosed with type 2 diabetes eight years earlier and was taking the medications sitagliptin, metformin, and glicizide to control his blood glucose. In addition, he had a history of high blood pressure and part of one kidney had been removed because of cancer.
We counseled him on a low-carbohydrate, healthy-fat diet and suggested that he start fasting for 24 hours, three times per week. Within six months, he was down to a single medication, canagliflozin, which he continued taking for a period of time to help with weight loss. After another year, we discontinued this medication as Simon’s weight and blood glucose had significantly improved. He has not needed any medications since.
At his last checkup, Simon’s hemoglobin A1C was 5.9%, which is considered nondiabetic, and he had maintained a 45-pound weight loss for two years and counting. Today, he is ecstatic about the change in his overall health. He has gone from wearing a size 46 pant to a 40, and the type 2 diabetes, which he believed was a lifelong disease, has completely reversed. Simon continues to follow a low-carbohydrate diet and fasts once or twice per week for 24 hours.
BRIDGET
When we first met Bridget, 62, she had a ten-year history of type 2 diabetes, chronic kidney disease, and high blood pressure. She was severely insulin resistant, requiring a total of 210 units of insulin every day to keep her blood glucose under control. She weighed 325 pounds, with a waist size of 147 cm and a BMI of 54.1.
Determined to get off insulin, she started with a seven-day fast but felt so well and so empowered that she continued for another two weeks. By the end of the 21 days, she had not only stopped all her insulin but required no diabetic medications at all. To maintain her weight loss, she switched from fasting continuously to fasting for 24 to 36 hours every other day, and she resumed taking dapagliflozin to help control her weight. During this time her A1C was 6.8%, which was actually better than when she was taking insulin.
Before starting the IDM program, Bridget had very low energy levels and could barely make it into my office on her own two legs. Once she started to fast, her energy levels improved significantly and she was easily able to walk around. Her dress size dropped from size 30 to 22. Bridget has been off insulin for three years now and has maintained a total weight loss of 63 pounds over that time. Her blood pressure has normalized and she has stopped taking medication.
DIABESITY: THE CALORIE DECEPTION
DIABESITY IS THE unification of the words diabetes, referring to type 2, and obesity. Just like the evocative “bromance,” it conveys the close relationship between these two ideas. Diabetes and obesity are truly one and the same disease. As strange as it may now sound, physicians did not always recognize this seemingly obvious and basic connection.
Back in 1990, when grunge was taking over the music scene and fanny packs were growing in popularity beyond the middle-aged dad tourist, Dr. Walter Willett, now Professor of Epidemiology and Nutrition at Harvard’s School of Public Health, identified the strong and consistent relationship between weight gain and type 2 diabetes.
The obesity epidemic had only just gotten underway in the late 1970s and was not yet the public health disaster it is today. Type 2 diabetes barely scratched the surface as a public health concern. Instead, AIDS was the hot topic of the day. And type 2 diabetes and obesity were not thought to be related in any way. Indeed, the Report of the Dietary Guidelines Advisory Committee issued by the U.S. Department of Agriculture in 1990 allowed that some weight gain after the age of thirty-five was consistent with good health.
That same year, Dr. Willett challenged the conventional thinking, reporting that weight gain after age eighteen was the major determinant of type 2 diabetes.1 A weight gain of 20–35 kg (44–77 pounds) increased the risk of type 2 diabetes by 11,300 percent. Gaining more than 35 kg (77 pounds) increased the risk by 17,300 percent! Even smaller amounts of weight gain could raise the risk significantly. But this idea was not an easy sell to a sceptical medical profession.2 “We had a hard time getting the first paper published showing that even slight overweight greatly increased the risk of diabetes,” Willett remembers. “They didn’t believe it.”
BODY MASS INDEX: THE RELATIONSHIP BETWEEN OBESITY AND DIABETES
THE BODY MAS index is a standardized
