One of the biggest problems with weight loss programs and diets is that even if they work the weight tends to come back on within a year or two. A recent study from the University of Utah of people who underwent bariatric surgery shows that not only do they lose weight quickly, after 6 years they continue to maintain their lower weight. After undergoing bariatric surgery the average weight drop was 35% of the original weight and after 6 years weight loss was still a very encouraging 28%. 75% of diabetics who had bariatric surgery were able to go off their diabetic medications, while improvements were generally seen in cholesterol levels and blood pressure.
Although this study shows a very high success rate, in the real world medical practice I have seen many people who are able to eat their way out of weight loss success after bariatric surgery. Eating small amounts of very high calorie food is still possible and unfortunately is not all that uncommon. Not to say that bariatric surgery is not helpful, because when it works the results can be spectacular, but as always the degree of motivation of the patient is crucial to success.
Gary Pepper, M.D.
Although we often speak of the metabolic effects of thyroid hormone, we are really referring to the fact that this hormone helps to regulate the function of every system in the body. A system that is often a source of concern is known as the integument; the hair, skin and nails. The effects of disease is often first noticed due to effects on the integument and thyroid disease is one of the most likely to show up here. Brittle hair that sheds easily, and skin that is dry, itchy and flaky are often noticed early in hypothyroidism. Here is Dana’s story and I’m hoping that the addition of T3 will help her lose her excess weight and also reverse the deterioration she is experiencing in her integument, and her nervous system (mood).
I was diagnosed as hypo a few years ago and my doctor just added 25 mcg of liothyronine (Cytomel) along with 100 mcg of Synthroid. In the past year I have gained 35+ pounds and it’s been alomost impossible to take it off. Last year I competed in my very first fitness/ figure competion. At 135lbs I came in 2nd place. I play softball and basketball on competitve level teams for the psat 15 years and I run about 3-4 times a week. I eat relatively healthy and have recent gone gluten-free, soy free, and nitrate free. Today is my very first day on the combined T3/T4 thereapy. I steppeed on my scale and it said 174lbs. Im hopeful that not only my weight will decrease but my hair will stopp shedding, dry skin/ scalp, joint pain, hopelessness and depression, and fatigue will all go away. I know patience is the key so I will be patient and wait.
As you read here, some people are unable to return to normal thyroid equilibrium on t4-treatment alone; this may be due to an inherited form of enzyme defect preventing the normal conversion of the t4 hormone into the more potent t3 hormone; I am happy you found a doctor who will prescribe T3. Sometimes this needs to be given twice daily since t3 is a short acting hormone and the benefit may wear off within 6 to 8 hours. Some people don’t notice this while others definately do.
Good luck with your treatment. Also remember, thyroid hormone allows you to lose weight normally but doesn’t make weight “melt off”. You still have to do the right things with diet and exercise but at least your efforts should start paying off.
Gary Pepper, M.D.
A potential new treatment for type 2 diabetes, dapagliflozin, recently failed to gain approval from the FDA. What makes this rejection noteworthy is that the new medication works by a completely new mechanism causing the kidney to excrete sugar from the blood into the urine. Reasons for the rejection were the increased risk of bladde and breast cancer in those taking the medication, increased urine and genital infections and possible liver toxicity. That list of problems seems pretty convincing to me. This is unfortunate because the drug appears to cause weight loss and does not cause low blood sugar (hypoglycemia). However, a drug that works by “poisoning” the kidney so that it dumps sugar into the urine strikes me as a drug that is going to cause a lot of other problems.
The other established diabetes medication generating new warnings is Actos (pioglitazone). I have written a number of articles on the sister drug Avandia, defending its usefulness despite possible cardiovascular risks, but the cancer warning for Actos is a new angle on this class of drugs (thiazolidinediones). Actos has been withdrawn in France due to concerns that it may cause bladder cancer but no such action has been taken in the U.S. The FDA this month did issue a warning that individuals with bladder cancer or at risk for bladder cancer, should be advised not to use Actos. If Actos is hit hard by these actions this whole class of diabetes drugs will have been eliminated from use.
A sure sign of trouble for Actos is that a “google search” for Actos is now showing lawyer websites as the first 5 citations.
Being sick is dangerous. Treating illness also has dangers. I am concerned that our cultural zeal for uncovering scandals and for pursuing litigation will lead us to sterile treatment options and doctors who are unwilling to risk helping.
Gary Pepper, M.D.
Editor in Chief, metabolism.com
Michelle shares her success story with T3. Michelle’s story demonstrates how combination therapy with T4 and T3 can be clinically superior to T4 (Synthroid, Levothyroxine) alone. In her story she mentions Wilson’s syndrome which I personally think is a “made up” diagnosis to help Dr. Wilson’s retirement fund but I do think her experience is fairly typical of a lot of people with hypothyroidism who eventually discover they need T3 added to conventional treatment with T4 to achieve best results.
OMG! Maybe I’m not crazy after all!
I’m 47 in December and can’t remember the last time I felt good or even okay. Same thing – doctors repeating same tests, thinking I’m exaggerating, sent to Psychiatrist…Over the past 6 years or so, major stress, low immune (sick all the time), worsening depression, borderline diabetes, high blood pressure, peri-menopause. Got to the point that I’m sooo exhausted. Don’t want to do anything. Lab diagnosis finally showed up hypothyroidism so doctor put me on Synthroid – I was so happy that I cried. Devastation set in after 6 months as this was not the miracle I thought it would be.
Started taking my temperature 3 to 4 x a day as suggested to me by a naturopath I had seen but couldn’t afford to keep going to. Again, measurements taken 3 x daily for a week averaged to 97.0. Talked to doctor about Wilson’s Temperature Syndrome; she did not believe in it and sent me for more blood tests which came back normal.
FINALLY (after 20 years at same doctor’s office) was lucky enough to be accepted under the care of a physician who hadn’t heard of WTS but had heard about the T4 not converting into the T3 (you all know the fault in the system)… so right then and there wrote me a prescription for Cytomel and told me to stop the synthroid. As the WTS website recommends sustained T3, I’m taking half the dose every 12 hours.
I started today and feel like a kid on Christmas Eve a million times over! I am so hopeful that this can get to the root of so many ailments. So many that I feel that I’m not even living my life, that I’m just here putting in everything I have just to get through the day.
With the lack of memory and concentration I have right now, I hope I remember to come back to this site and update you all!
A few days ago I was concluding a visit with a patient with thyroid disease, while her diabetic
husband, also my patient, looked on. They are a pleasant older couple I have known for
years, who are devotedly helping each other stay healthy. As they were leaving the exam room the
wife apologetically turned the subject to her husband mentioning he was having almost
daily “episodes” of weakness and confusion. “I hadn’t changed his diabetic medication recently
so why should his blood sugar be an problem now”, I thought. A number of other unpleasant
possibilities immediately occurred to me. I inquired about signs of a possible stroke or heart
condition. If these other angles were unproductive I faced the choice of sending him to the
hospital for an evaluation. We quickly ran through a routine systems review. He had lost 10
lbs in the past month, the wife mentioned. “Oh, no, cancer” , was my first thought. His wife
explained that as a New Year’s resolution he enrolled in a commercial weight loss program for
diabetics. With relief, I knew we had the explanation of his disturbing new symptoms.
Most of my diabetic patients are on medication since they are unable to maintain good glucose
control with diet and exercise only. If they succeed however, in achieving weight loss then the
diabetes medication must be reduced to prevent undesirable hypoglycemia (low blood sugar).
Hypoglycemia is potentially dangerous because the brain cannot function properly resulting in
abnormal behavior, loss of muscle control and even unconsciousness. Imagine this occurring
while behind the wheel? Down here in Florida this is all too common.
Many commercial weight loss programs have started targeting Type 2 diabetics (adult onset)
with their TV ads. These programs are generally administered by people without any medical
background. They cannot advise medication changes (not that you would want them to) without
breaking the law by practicing medicine without a license. The result, as with my patient, is the
development of potentially serious complications of hypoglycemia.
In a previous blog http://www.metabolism.com/2010/10/17/injured-diabetic-diet , I worried that this type of problem could develop with commercial weight loss programs. I didn’t expect to see evidence of it so soon and in my own exam room. If my patient’s wife didn’t stop and mention his new symptoms at the last moment
that day, I imagine a far worse outcome for her husband was possible.
Gary Pepper, M.D.
Dael is taking a lonely path as a confirmed smoker. So far the benefits seem to out weigh the risks, but we all know what the end of this road will look like. I am posting Dael’s comments to see if the community at metabolism.com can make a positive impact on Dael’s rebellious attitude.
hey guys and gals just to let you know,
am down to 130lbs and feeling fit as a fiddle. have the 6 pack and abs i dreamed of and am fitter than i have ever been.. it really is odd cos i hate smoking but here i am having lost 42 lbs and loving every second of it apart from the smoking. what can i say – maybe rather die skinny and liking myself, than a fatty with some self righteous notion of how wonderful i am for not smoking… i hated myself with the extra weight, sorry but true…. i really can’t give a f***k for what anyone thinks on here but at least i can bear to look at myself in a mirror and like what i see, not loathe what i look like and try to bullshit myself into believing that i am sooooo happy cos i gave up the cigs….. but next is the NRT – lets see what happens there, and b4 anyone says it, yes i lost two of my best friends to cancer, of the spine and brain, but all i can say is like james dean , i’d rather live fast and furious, that be fat and dumb til 101, you can all choose, but in the end what do you all want?
i do not advocate smoking !!!
I know who i am
Ads on TV and in magazines are promoting weight loss programs specifically designed for diabetics. Weight loss is crucial to successful treatment of type 2 (adult onset) diabetes and is a highly desirable goal. In practice however, weight loss diets for diabetics can be dangerous if not properly supervised. Many adult diabetics are taking powerful medications to lower their blood sugars. These medications can work through several different mechanisms in the body, some of which can lead to hypoglycemia which is abnormally low blood sugar. Hypoglycemia may occur almost without warning resulting in rapid heart beating, sweating, confusion , poor coordination and even unconsciousness. When a diabetic begins a weight loss program, if their medication is not adjusted appropriately the risk of hypoglycemia goes up dramatically.
Most of the weight loss programs being advertised are designed by professionals but administered by non-medical personnel. Although their over-all goal is a good one, it seems to me that these programs are putting people at risk and are equivalent to engaging in practicing medicine without a license. It is careless to assume that the dieter’s doctor will be in a position to immediately make accurate medication adjustments when the diet begins.
Have you ever come across ads from lawyers soliciting clients who have been injured by products, including prescription medications? My thought is that soon these lawyers will be soliciting business from people who developed hypoglycemia on commercial diabetic weight loss programs, resulting in injury to themselves or others.
Gary Pepper, M.D.
As a culture we don’t plan for a sudden halt in scientific advancements. Our tendency is to expect progress to be rapid and continuous. My prediction is that in certain areas of medical science we are likely to see not only a halt in progress but a slipping backward. In particular, the realm of medical weight management is in complete disarray at this time. Two new drugs designed to induce weight loss have been shot down by the FDA in the last few months. The first is Qnexa, developed by Vivus Inc. Interestingly, Qnexa combines two drugs already approved for use in the U.S. One of the drugs is phentermine which is a medication used for decades as an appetite suppressant. The other is a common drug used to treat seizures with the brand name Topamax (topiramate) which also induces weight loss. The drug performed admirably in clinical trials with most participants losing over 10% of body mass. The FDA cited excessive risks of the drug in its statement of rejection. One wonders why the drugs are still being marketed separately if they are so dangerous.
The latest drug to be rejected by the FDA is Lorgess (lorcaserin), developed by Arena Pharmaceuticals. This drug, not as effective as Qnexa, produced 5% body mass loss in about half of participants in clinical trials. Lab animals showed a tendency to develop breast tumors when exposed to the medication, adding to the FDA’s decision to reject the drug application based on safety concerns.
I am a strong advocate of drug safety and regulation. On the other hand we know obesity, and with it Type 2 diabetes, is epidemic in the U.S. I regard weight loss as the “holy grail” when treating type 2 diabetes and yet it is the most difficult goal to achieve. Any drug which could assist in weight loss is highly desirable in the treatment of Type 2 diabetes. Not only does blood sugar improve with weight loss but also blood pressure and cholesterol readings show declines. All three of these parameters are known to be prime contributors to the main cause of death in diabetics, cardiovascular disease.
It has already been 10 years since the last drug was approved specifically for a weight loss indication. The failure of these two latest medications to achieve approval is certain to cause the pharmaceutical industry to severely curtail if not abandon further investment in this type of drug development.
Why is the FDA so reluctant to approve a weight loss pill? This is a complex issue but requires an answer. A new weight loss inducing medication is certain to be highly anticipated and widely prescribed. Therefore, from the very first day of approval the FDA must take responsibility for the well being of millions of people who are likely to take the medication. We are a society which demands our medications deliver miraculous cures with no side-effects. If someone perceives they have been injured by a medication our legal system is primed to unleash brutal retribution on everyone remotely involved in the approval process. Abuse and injury with a medication designed to cause weight loss is almost a certainty. This is a no-win situation for the administration of the FDA.
I predict it will be at least another 10 years before a medication for weight loss is approved by the FDA. Unless there is a change in the climate of litigation in this country it will take longer than that. In the meantime the only new developments in weight loss drugs will be the result of exploiting appetite suppressant effects which are the “side-effect” of medications approved for other purposes.
Gary Pepper, M.D.
It seems obvious that cutting away part of the stomach and intestine should cause weight loss. With a smaller stomach and less intestine fewer calories can be absorbed per day causing weight loss. Surgeons who perform gastric by-pass were puzzled however, by how fast their patients showed metabolic improvement after undergoing this procedure. They noticed many of their diabetic patients could be taken off diabetic medication immediately after surgery before weight had been lost. Scientists looking into this phenomena discovered unsuspected ways gastric by-pass improved metabolism.
The intestines produce hormones which regulate blood sugar and appetite. GLP-1 is among the best known of these intestinal hormones. GLP-1 is the basis of a whole new generation of medications used to treat diabetes such as Byetta, Victoza, Januvia and Onglyza. GLP-1 lowers blood sugar, stimulates the pancreas and reduces appetite. After gastric by-pass increased amounts of GLP-1 are produced by the remaining intestine. In a study published in the Journal of Clinical Endocrinology and Metabolism (95:4072-4076, 2010), researchers at St. Luke’s Hospital in New York discovered that levels of oxyntomodulin, another intestinal hormone that suppresses appetite and acts like GLP-1 on blood sugar levels, is doubled after gastric by-pass.
These exciting discoveries help explain why obese diabetics can often be sent home without any medication to control blood sugar immediately after undergoing gastric by-pass surgery. Although most insurance plans do not cover gastric by-pass surgery, dramatic improvements in patients after the procedure with greatly reduced medication costs may convince insurance companies that paying for the procedure will result in better outcomes and save them money in the long run.
Gary Pepper, M.D.
After reading the latest research on the metabolic hazards associated with chubby necks I am more sensitive to the size of people’s necks then ever. Of course I look at the size of my patient’s neck but people who I pass in the street or supermarket may find me staring. Watching TV a few days ago I was startled by a series of people in one commercial for Quicken Loans who definitely qualify for the metabolic high risk category based on neck chubbiness. One after another the characters in this commercial walk on, outdoing each other in this physical trait. Has the chubby neck become the new normal? If so, the incidence of diabetes and heart disease is sure to continue to rise.
Let me know if you agree with my impression, or am I biased by being an endocrinologist?
Gary Pepper, M.D.