The diet plan described in this book should make it possible for virtually any diabetic to achieve essentially normal blood sugars. There are, however, three exceptions.* The first, as I’ve mentioned, is the presence of gastroparesis, or the partial paralysis of the stomach, and other ailments that can impair stomach-emptying or digestion. These may include hiatal hernia, stomach or duodenal ulcers, a “tonic” (tight) stomach, gastritis, duodenitis, celiac disease, and scleroderma, among others. The next is infection. The third is the inability to control food intake, but especially carbohydrate intake. Because of the thrifty genotype, we should expect to find this condition in many type 2 diabetics. Indeed, about half of my type 2 patients find it extremely difficult to remain on a low-carbohydrate diet—or indeed any kind of structured diet. Typical scenarios include snacking when bored, eating bread in restaurants for no better reason than that it’s on the table, and eating everything on your plate regardless of any actual hunger if you happen to be given a too-large portion, often at restaurants. Others may eat a whole pint, and some even a quart, of ice cream every night, often because they feel they have nothing else to do. At least 10 percent of my type 1 diabetic patients also have such problems, but their problems, when they occur, have a more devastating effect on blood sugars. These are the people who rapidly develop retinopathy, numb feet, kidney dysfunction, and so on.
Some years ago, I recalled how, in medical school, I had been taught a technique for self-hypnosis in order to avoid falling asleep when we had boring speakers and the lights were turned off. I wondered if perhaps the same technique might be helpful to those patients who just couldn’t seem to stick to a low-carbohydrate diet or any other. I decided to get in touch with the physician, Herbert Spiegel, MD, who had taught me autohypnosis.
Remarkably, he was still in the same office at the same telephone number as more than twenty years before. To my amazement, he told me that he routinely used this technique to treat people with eating problems. Put this under the category of reasonably important discoveries I had missed. In fact, with his son, David, he had even written a book, Trance and Treatment: Clinical Uses of Hypnosis. It includes a chapter on just this subject. I subsequently referred many patients to him to learn this technique, with success in helping people break the cycle of carbohydrate addiction. (Dr. Spiegel used this method for altering a number of different behaviors, not just weight loss or the propensity of elderly medical students to snore during soporific lectures.)*
The whole cycle of going into a hypnotic state, giving yourself a message, and coming out of the state takes initially about 1 minute. Once you have some experience, it takes only about 20 seconds to complete. The technique only works if you’re hypnotizable. A qualified medical hypnotist quite readily can determine whether you are a suitable subject. One of the things the specialist looks for is how high you can roll up your eyes as you attempt to look toward the top of your head. Additionally, the technique will only work if you perform autohypnosis at least 10 times daily (for a total of about 3½ minutes per day). The section below, which is adapted with permission from Dr. Spiegel’s book, is the handout that our eminent consultant gave to his patients with eating problems. This handout is a reminder of what they were taught in his office.
Sit or lie down. At first, being in a quiet place can help. To yourself, count to three. At one you are going to do one thing, at two, you will do two things, at three, you will do three things.
Without moving your head, look upward toward your eyebrows, all the way up.
Close your eyelids and take a deep breath.
Exhale; let your eyes relax and let your body float.
As you feel yourself floating, you permit one hand or the other to feel like a buoyant balloon and allow it to float upward. As it does, your elbow bends and your forearm floats into a vertical position. Sometimes you may get a feeling of magnetic pull on your hand as it goes up. When your hand reaches this vertical position, it becomes a signal for you to enter a state of meditation and increase your receptivity.
In this state of meditation, you concentrate on this feeling of imaginary floating and at the same time concentrate on these three messages:
For my body, overeating is a poison.
I need my body to live.
I owe my body this respect and protection.
In the beginning, do these exercises as often as 10 different times a day,† preferably every 1–2 hours. At first, the exercise should take about a minute, but it will come more rapidly with practice.‡
As you meditate, reflect on the implications of these critical points and then bring yourself out of this state of concentration by counting backwards in this manner: Three, get ready; two, with your eyelids closed, roll up your eyes (do it now); and one, let your eyelids open slowly. Then, when your eyes are back into focus, slowly make a fist with the hand that is up and, as you open the fist slowly, your usual sensation and control returns. Let your hand float downward. This is the end of the exercise, but you retain a general, overall feeling of floating.
By doing this exercise (at least) 10 different times each day, you can float into this state of buoyant repose. Give yourself an island of time. Twenty seconds, 10 times a day, in which to use this state of extra receptivity to reimprint these three points. Reflect upon it, then float back to your usual state of awareness and get on with what you ordinarily do.
Now, suppose an hour or two passes and you want to do the exercise. You don’t have the privacy and you don’t want to attract attention. Here’s the way to camouflage. There are two changes. First, you close your eyes and then roll your eyes up, so that the eye roll is private. Second, instead of your hand coming up as done in the hypnosis session [with the hypnotist], let it come up and touch your forehead. To an outsider, the exercise looks as though you are in deep thought. In 20 seconds you can shift gears, establish this extra receptivity, reimprint the critical points, and shift back out again.
You might be sitting at a desk, a table, or maybe in a conference, in which case you lean over on your elbow with your hand already on your forehead, you close your eyes, roll them up, and shift into the brief meditative state.
By doing this basic or camouflaged exercise every day, every one or two hours, you establish a private signal system so that you are ever alert to the messages you are sending yourself and the commitment you are making to yourself and your good health.
It is possible but unlikely that you will be able to master this technique without training from a professional medical hypnotist. Sufficient training should be possible to accomplish in a single office visit with a doctor trained in medical hypnotism. I stress the necessity of using the services of a doctor because I have had patients who, upon visiting nonphysician hypnotherapists, were convinced (you might even say conned) that many office visits were necessary, and spent considerable sums but failed to learn the technique. (If the word “hypnotism” automatically conjures up images of charlatans and carnival sideshows in your mind, this may be a reason.)
You should be able to locate a competent medical hypnotist by phoning the department of psychiatry at the nearest medical school or teaching hospital. Ask for the secretary/assistant to the chairman of the department, and then ask who their top MD hypnotherapist is. Your insurance may or may not cover the visit, depending on your plan, but it almost certainly will not pay for a nonphysician hypnotherapist.
When you visit the MD hypnotherapist, bring either this book or a photocopy of the above paragraphs so that he or she will know exactly what you are seeking.
In Trance and Treatment Dr. Spiegel is very emphatic on the following:
Accept responsibility for Your Eating Behavior. It is very tempting to blame your eating behavior on your parents, your wife, the mayor, Watergate, the moon, the tides. As soon as you see the absurdity of that you will realize that of all the things you do in life, there is nothing in which you are more clearly 100 percent responsible than your eating behavior. Reflect on the fact that most of the things you do in life have to take into account other considerations or other people, but in your eating behavior you are in business for yourself.
I should note that Dr. Spiegel’s three points, or messages, were developed for the treatment of obese overeaters, not necessarily diabetics but certainly people at higher risk for developing type 2 diabetes. For many of my patients, his three points hit the mark. For others, the points they want to stress are more closely attuned to their personal situations, and you can customize your approach as well. I have one patient who is simultaneously losing vision and kidney function. This patient’s personal points are to curb overeating in order to preserve eyesight and to stay off dialysis. Another tells herself that she doesn’t want to be like the lady who lived across the street from her when she was a kid—the woman was diabetic and had both her arms and legs amputated. Another patient is a fund-raiser—his points are attuned to the greater likelihood of people making donations to someone who is slim and trim rather than obese. Makes sense.
Some people have a difficult time remembering to hypnotize themselves every 1–2 hours, so for these people, I recommend an alarm watch (which you can purchase quite reasonably) that can be set to go off every hour. Get one that has a vibration mode if you don’t want to be beeping regularly.* Alternatively, you can set the alarm on your cell phone.
For those who learn how to hypnotize themselves and do it 10–15 times a day, I’ve found that the success rate for curbing carbohydrate craving is about 80 percent. For those who self-hypnotize fewer than 10 times a day, the success rate is essentially zero. I cannot overemphasize the value of engaging in autohypnosis when you sit down at a table for a meal, especially if you’re in a restaurant and have not yet ordered. I have patients who are walking around with normal blood sugars only because they have been successful in using this technique. It has the added benefit of having no toxicity whatsoever, and it might be used to change other behaviors (smoking, biting fingernails, and so on).
There is, however, a major problem with autohypnosis. I find that many patients either refuse to try it or eventually stop doing it, even when it works. The following section offers a solution to overeating that people have been more than willing to pursue and continue to use.
I have a simple, patented technique that has had success for a few of my patients who otherwise have great difficulty controlling carbohydrate intake. It relates to the “runner’s high” that people often experience during and after exercise, but it doesn’t require running.
You may already know that very strenuous, prolonged physical exercise and climactic sexual activity cause the brain to produce endorphins, also known as the body’s own opiates because they are produced internally (or endogenously—so they’re known in medical circles as “endogenous opiates”) and bind to receptors in the brain that also bind actual opiates, such as morphine and codeine. Endorphins cause a pleasant, relaxed feeling, similar to that created by narcotics, but to a milder degree and without producing a tolerance.* You may have noticed that serious runners and many professional athletes tend to prefer protein foods, don’t crave carbohydrate, and don’t become fat as long as they continue their sport. It would seem that their endorphins prevent overeating and carbohydrate craving without losing their effect over time as do traditional appetite suppressants.
This technique involves a medication called naltrexone, which was originally introduced as a treatment for narcotics addicts because of its ability, in large doses, to prevent addicts from getting high on narcotics. In large doses, naltrexone will block the brain’s receptor sites for endorphins, rendering them ineffective. However, when taken in small doses, it also appears to raise endorphin levels in the brain.
A very small dose of naltrexone taken at bedtime seems to block endorphin receptors for about 8 hours. The brain may then compensate for this by making more endorphins than usual that then keep working throughout the following day, when receptors are no longer blocked.
I’ve found that a small dose of naltrexone used in this way is effective in controlling carbohydrate addiction and overeating in general for a few of those who have tried it. Furthermore, just like the endorphins made by athletes, naltrexone, thus far in my experience, seems to work for a prolonged period—perhaps indefinitely.
I’ve had only five patients who discontinued naltrexone because of uncomfortable side effects. These effects included tiredness, headache, and difficulty concentrating on complex tasks. Such problems always occur after the first dose. When they occur, I must discontinue the medication.
One patient who snacked between dinner and bedtime also had insomnia. Since naltrexone made him tired, we were able to use it to treat his insomnia and his snacking simultaneously.
Naltrexone is supplied in 50 mg tablets. For the low dose that I prescribe, I use a compounding chemist to put naltrexone powder into small capsules—usually about 4.5 mg.*
Although in the past I’ve prescribed naltrexone at various doses and at different times of the day, I changed this to 4.5 mg at bedtime at the suggestion of Dr. Bernard Bihari, who has prescribed it for ailments other than overeating. This dosing method indeed appears to be the most effective.
As with the other suggestions in this book, ask your physician to give low-dose naltrexone a try. He should pay particular attention to the package insert warnings against overdosing. For other remarkable uses for low-dose naltrexone, visit the website www.lowdosenaltrexone.org.
I patented this mode of using naltrexone, in order to encourage its distribution by pharmaceutical companies in low doses. Unfortunately, I allowed the patent to lapse shortly before a drug company released a mixture of naltrexone and Wellbutrin.
Another product has curbed overeating in many of the patients for whom I’ve recommended it. This is hoodia, a nonprescription extract of a South African cactus. The brand I prefer is HoodiaXtra 1,000 mg. It is available online at www.diabetes911.net. Other brands, usually in smaller doses, may be purchased at health food stores, www.rx4betterhealth.com, and other websites. Since hoodia begins working within 30–60 minutes, it should be taken about 1 hour before an anticipated need. Thus, if you usually overeat at dinner and then snack thereafter, you might take 1–3 capsules before dinner and another 1–3 after dinner. Some sources of hoodia supply a timed-release version. It is most effective when taken on arising and again 6–8 hours later.
I have seen no adverse side effects from this product, but I have never used it in children.
Because the demand for hoodia now exceeds the supply, many phony formulations are being marketed, especially on the Internet. To secure a reliable product, you would be wise to use a known brand supplier and a product without additives that may dilute its strength.
I believe that carbohydrate craving is truly an addiction. This addiction can be reinforced by the consumption of foods on our No-No list (here). So once you have discontinued them, I recommend never trying them again or you will likely relapse. Even a small taste can cause you to fall off the wagon—just as for smokers, alcoholics, and other drug addicts.
You may recall from our discussion of the Chinese restaurant effect (see here) that intact pancreatic beta cells make a hormone called amylin. Amylin release into the bloodstream is brought about in response to a meal, by gut hormones called incretins. Since diabetics do not have beta cells that function adequately, they make little or no amylin and therefore may not experience the degree of satiety that nondiabetics do. As a result, they are more likely to remain hungry after a meal and thus to overeat at meals and snack between meals.
Perhaps the most exciting class of drugs to hit the market in many years actually solves this problem. Products in this category are called incretin mimetics (IMs)—that is, they imitate the effects of incretins or of amylin. What is so special about them is that in my experience they really work, and they do so for about 90 percent of users, a very high degree of success. At present these products are sold to lower blood sugar after meals. Our application to overeating is therefore considered “off-label” but is permitted by the FDA if prescribed by a physician. Field trials of IMs to prevent overeating by the general population are now progressing. If IMs are tested in combination with low-carbohydrate diets (unlikely), the stocks of several drug companies will go through the roof.
The most effective IMs, at this writing, must be administered by injection one or more times daily. The good news is that the needles are tiny, so these injections are painless if you follow our injection technique, described in Chapter 16. A once-weekly version may become available, and four oral versions (Januvia, Onglyza, Tradjenta, and Galvus) are now on the market. But start with the injections, because they are much more likely to work.
For example, I saw a new patient who weighed 286 pounds (130 kg) and had an HgbA1C of 6.9 percent when we first met. I started her on an IM, and over a period of slightly less than a month and a half (44 days), her weight came down to 258 pounds (117.3 kg) and her HgbA1C dropped to 5.2 percent. Thus she lost an average of nearly ¾ pound per day and her three-month moving average blood sugars dropped from 176 mg/dl to 108 mg/dl. Her highest blood sugar of the final week of this period was 95 mg/dl. Since the first dose of the new medication, she has been able to follow our low-carbohydrate meal plan without hunger, cravings, or any snacking.
The incretin mimetics fall into three categories:
Amylin analogs. The only one being marketed in 2011 is Symlin (pramlintide). It is marketed by Amylin Pharmaceuticals, Inc. It is chemically similar to amylin and performs the same functions in the body. It is only available for injection.
GLP-1 mimetics. GLP-1 is one of the hormones secreted into the bloodstream by the intestines that tell the beta cells of the pancreas to secrete amylin, insulin, and glucagon. GLP is an abbreviation for “glucagon-like peptide.” The two versions currently on the market are Victoza (liraglutide), sold by Novo Nordisk, and Byetta (exenatide), jointly marketed by Amylin Pharmaceuticals, Inc., and Eli Lilly and Company. Both are available only for injection. Human GLP-1 has a half-life in the bloodstream of less than 2 minutes, so in nondiabetics it is secreted continuously for as long as it is needed. The GLP-1 analogs have been modified to last several hours (Byetta) and an entire day (Victoza). A GLP-1 analog that lasts an entire week is being tested, but it is not as potent as Victoza. Additional GLP-1 agonists may become available in the future.
DPP-4 inhibitors. DPP-4 is an abbreviation for dipeptidyl peptidase-IV, the enzyme that the body uses to destroy GLP-1. Administration of its inhibitor opposes the destruction of naturally produced GLP-1. This, in theory, circumvents the need for injecting a GLP-1 mimetic. As of 2011, four oral products are being marketed in this category:
Januvia (sitagliptin), Merck and Company—sold in United States
Onglyza (saxagliptin), Bristol-Myers Squibb—sold in United States
Tradjenta (linagliptin), Boehringer Ingelheim—sold in United States
Galvus (vildagliptin), Novartis—sold in European Union
Several similar products may be released over the next few years. All of the above oral products are meant to be taken once daily.
The FDA and the reigning powers in diabetes care have approved the use of IMs solely for lowering blood sugar. In clinical trials, they were shown to lower HgbA1C by a marginal amount—about 0.5–1 percent. They also caused a small amount of weight loss in some users. Had the patients in these trials been taught to avoid the high-carbohydrate foods commonly advocated for diabetes, the satiety effects of the IMs would have generated dramatic drops in both blood sugar and weight among obese overeaters. These are the effects that I seek when I prescribe them.
The conventional use of the GLP-1 agonists is to stimulate insulin production in type 2 diabetics. This small effect rarely justifies their use. Because type 1s don’t make insulin, nor amylin in response to GLP-1, the reigning powers do not support GLP-1 agonists for their treatment. Yet I find that many type 1s, like type 2s, benefit from the satiety effects of these agents. I cannot explain why they work for type 1s who theoretically cannot make amylin in response to GLP-1.
The reigning powers do permit the use of the amylin analog Symlin for type 1s because it reduces the blood sugar by inhibiting the effect of glucagon at mealtime. Again, I use it for its commonly ignored satiety effect.
There is one catch when using IMs for type 1s. Most type 1s have had high blood sugars for more than five years and are therefore likely to have at least some degree of gastroparesis, or delayed stomach-emptying. Since one of the actions of amylin (and therefore the other incretin mimetics) is to slow stomach-emptying, gastroparesis is likely to worsen. As explained in Chapter 22, severe gastroparesis can make blood sugar control impossible. If I am faced with a type 1 diabetic who has mild to moderate gastroparesis but who also snacks on carbohydrate or overeats, I must then decide which will disturb his blood sugars more, the eating behavior or the gastroparesis. This can be a tough call, but the decision can be facilitated with the help of the R-R interval study described in Chapter 22. Any physician contemplating this problem should certainly read that chapter.
Because these hormones will naturally slow stomach-emptying, they may cause nausea—even in people without gastroparesis. For this reason, we usually start at the lowest reasonable dose and increase it over time (days to weeks) until the full satiety effect is reached. Fortunately, nausea is the only adverse effect my patients have had over the past five years. It usually goes away at lower doses and after time has elapsed for adaptation.
I have one very obese patient who only overeats at restaurants and parties. He has moderate gastroparesis. I therefore have him taking Symlin only before eating out. Fortunately, this strategy is working.
Virtually any prescription medication has a potential for adverse side effects, and the IMs are no exception. Since they do slow stomach-emptying, their most common adverse effect is gastrointestinal disturbances such as nausea, constipation, stomachaches, and even diarrhea. It is therefore wise to start all of them at a low dose and work up slowly if necessary.
Manufacturers of Symlin and Byetta say they must be injected about 1 hour before breakfast and supper. Instead, I prescribe these IMs about 1 hour before the overeating or snacking usually occurs. For those who snack only in the late afternoon and otherwise stick to our meal plan, I prescribe it for use about 1 hour before the usual time of afternoon snacking. Strangely, some users find that Symlin must be injected 2–3 hours before the targeted time for it to be effective. Therefore timing of injections is a matter of trial and error.
Recall that amylin also reduces the body’s production of or sensitivity to glucagon—the major culprit in the Chinese restaurant effect. Between the reduced overeating and the reduced glucagon effect, blood sugars can be much lower after meals—even dangerously low if you take blood sugar–lowering medications of any kind. It is therefore necessary that your physician lower your doses of these agents at the time you start any incretin mimetic.
How much should doses be lowered? To some extent it comes down to experimentation. I usually start by lowering premeal medications by about 20 percent. I then may look at blood sugars the next day to see if dosing of these medications should be increased or decreased.
Byetta, Symlin, and Victoza are all supplied in prefilled pen injectors. Each pen comes with an instruction sheet that should be followed carefully. Future injectable IMs will likely also be in pen injectors. Tiny needles for the pens are sold in boxes of 100 and must be ordered with a separate prescription. The needles may be reused until they become dull or bent.
All pens must be primed before the first use. This is achieved by squirting the first dose into a sink or basin in order to fill the needle. Subsequent doses do not require repriming. Once the pen is fired by pressing a trigger button, it takes about 5 seconds for the full dose to be expelled, so slowly count at least 5 seconds before removing the needle from your skin. Read about our painless injection technique here.
The pen cases can usually be pried open to expose the vial of medication, making it possible to use an ordinary insulin syringe to withdraw doses smaller than those set by the manufacturer. The following specifications for these pens include the dose one would get by injecting ½ unit from an insulin syringe (see here).
Byetta. Two pens are available:
The 5 mcg pen dispenses 60 doses of 5 mcg each and has a total volume of 1.2 ml (0.02 ml per dose).
The 10 mcg pen dispenses double the volume of liquid, or 0.04 ml per dose.
The concentration of the IM in each syringe is the same, but the volume each pen injects is different. If using a standard insulin syringe, ½ unit will contain only 1.25 mcg.
Symlin. One pen is provided that can be set for two different doses: 60 mcg or 120 mcg. The total volume of 2.7 ml will dispense 45–60 mcg doses or 22–120 mcg doses.
It appears to me that Symlin is more potent than Byetta, so there may be an advantage for some individuals to use an insulin syringe to dispense very small doses. One-half unit in an insulin syringe will contain only 5 mcg.
Victoza. One pen is provided that has numbered settings with detents at 0.6 mg, 1.2 mg, and 1.8 mg. Intermediate doses can be set by using 10 audible clicks between each pair of numbers. This 3 ml pen will dispense thirty 0.6 mg doses, fifteen 1.2 mg doses, or ten 0.18 mg doses. When using an insulin syringe for very small doses, ½ unit will contain only 0.03 mg.
I usually start patients who weigh less than 150 pounds on 2–4 units from an insulin syringe (see Figure 16-4, here), taken 30–60 minutes before their usual episodes of overeating or snacking. So if someone overeats only at supper, she would inject about 1 hour before supper. If someone else snacks between 9 P.M. and midnight, he’d inject at 8 P.M. and, if necessary, again at 10 P.M. If a person overeats only when eating out, he’d inject about 1 hour before he anticipates arriving at the restaurant and not on other days. If another person snacks all day long, she might inject on arising and every 3–4 hours thereafter.
If someone gets adverse side effects (I’ve seen only nausea), we’d cut back to a lower dose until the side effects diminish, then increase each dose ½ unit per week until either cravings vanish or side effects reappear. If no adverse effects appear initially, each dose might be increased by 2 or 4 units until cravings cease. Heavier people might start at higher doses, with larger increases, and use the pen instead of a syringe.
If doses total 600 mcg over the course of a day without a major effect on appetite, I would assume that the medication is ineffective.
Until we have a once-weekly dose of Byetta (which seems unlikely), it will be necessary to focus dosing on the times of day when overeating or snacking occurs. This means starting with the 5 mcg prefilled syringe (orange label) and injecting about 1–2 hours before times of snacking or overeating occur.
If you overeat only at one meal, inject about 1–2 hours before that meal. If 5 mcg helps partially, the dose can be increased to 10 mcg by either injecting two 5 mcg doses or 1 dose from the 10 mcg (blue label) pen. If the eating problem occurs several times daily, 5–10 mcg should be injected 1 hour prior to each time of the day when the problem eating usually occurs. The theoretical maximum daily dosage of Byetta is 20 mcg, but very obese people may need higher doses. For type 1 diabetics, Symlin may be more likely to work than Byetta.
Januvia, Onglyza, Tradjenta, and Galvus are oral DPP-4 inhibitors that are meant to be taken once daily. In my experience, they have had no effect upon satiety and a slight effect upon blood sugar. They all have relatively benign adverse effect profiles. I have used them for patients who cannot quite achieve normal blood sugars with maximum doses of Glucophage (see here) plus Actos and need to add another medication but don’t want to use insulin. These products would likely get an average blood sugar of 95 mg/dl down to our usual target of 83 mg/dl. I doubt that they would be effective for type 1 diabetics.
Another potential application of the DPP-4 analogs is to prolong the effects of the injected GLP-1 analogs. I’ve tried this, but with only marginal effectiveness.
I apologize for saving the best for last in order to appropriately emphasize the value of this injectable medication in curbing overeating, snacking, and carbohydrate craving. Victoza is a once-daily (long-acting) GLP-1 agonist, marketed initially in 2010. It is very effective and usually lasts the 24 hours claimed by the manufacturer. This means that it can usually be taken at any time of the day. Nevertheless, if somebody has problems only after dinner, I would prescribe it to be taken an hour or two before the eating problem usually begins. A brief guide to using the Victoza pen appears here. I have seen only one case of nausea, when a patient took two 1.2 mg doses by mistake when first using it. I’m sure that sooner or later I’ll see more instances of reversible nausea.
Although the manufacturer recommends a maximum dose of 1 full pen (1.8 mg) daily, I’ve used as much as two 1.8 mg doses per day without any problems.
I have seen patients using autohypnosis, low-dose naltrexone, and even just low-carbohydrate diets who, after one year, found that they no longer had cravings for carbohydrates or excess food, even when they discontinued hypnosis or naltrexone. This is probably akin to some studies of depressed patients treated with certain antidepressants: after a period of time, the antidepressants may no longer be needed. Metabolic brain scans sometimes show an apparently permanent normalization of brain function in selected regions. For all we know, this may apply as well to the incretin mimetics.
One of my Symlin patients found that it ceased working after two months of use. She discontinued it for one week and restarted at a lower dose. The lower dose is still working after two and a half months.
A number of my patients found that their injectable IM lost effectiveness after several months, but that they were able to prolong satiety by switching agents every few months.
In any event, the improvement in blood sugars and concomitant weight loss are major incentives to give these methods a try.
The manufacturers of these products have reported that animal studies show regeneration of the pancreatic beta cells that make insulin and amylin. Whether this occurs in humans has not yet been demonstrated in the scientific literature. Animal studies over many years have shown small increases in the incidence or progression of rare thyroid C-cell cancers. This problem has rarely been reported in humans. On the other hand, substantially increased risk of twenty-four different cancers has been observed in poorly controlled diabetics before the advent of these products. A possible slight increase in the incidence of reversible pancreatitis in humans at high risk (such as alcoholics) has been reported for IMs. A sign of pancreatitis would be sudden, severe, unexplained abdominal pain extending through the body from back to front. Although pancreatitis is very rare, you should take any abdominal pain seriously. Stop the IM immediately and advise your physician of the situation. He or she can confirm pancreatitis by testing your blood for pancreatic amylase and lipase.
Another rare adverse effect is possible kidney failure in those who already have kidney deterioration. On the other hand, IMs have also been found to reverse early diabetic kidney disease. I recommend that IMs not be used for those with elevated serum creatinine or significant protein in the urine.
This is the latest fad to prevent overeating and even partially reverse diabetes. Many procedures are in use, from the adjustable Lap-Band to total removal of the stomach. Although surgical mortality at many centers is less than 1 percent, the subsequent complications of gastric surgery are legion. Several grossly obese people have come to my office as a last resort before surgery, and one patient came in after failed Lap-Band surgery. In all these cases, overeating was terminated with incretin mimetics. It is interesting that the ADA recommends gastric surgery as a treatment for obesity but has not embraced the combination of a low-carbohydrate diet and IMs.
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