From the comments I have received on my Facebook Page regarding type 2 diabetes, many of them have focused on the considerations for weight loss. Therefore, I said I would write an article on the key considerations for weight loss in type 2 diabetes.
What I didn’t want to do however is provide the same generic weight loss article which you have no doubt seen time and time again. Therefore, I thought I would try to focus on some of the behaviours I commonly see which prevent weight loss.
I will then talk about more specific dietary strategies to manage your type 2 diabetes and weight. I hope the article is a bit different and gives you some useful ideas.
With any weight loss plan there are some basic considerations required in order to keep you safe. Diabetes is a condition whereby some patients may be taking medications which can induce hypoglycaemia (too low blood sugar). Examples of these medications are insulin and the sulphonylureas such as Gliclazide, Glimepiride, Glipizide, Gilbenclamide and Tolbutamide. These medications will be prescribed based on your current blood glucose profile. We know weight loss improves blood glucose levels. Therefore, any weight loss plan may require adjustments to your medications to prevent dangerous episodes of hypoglycaemia.
I would therefore urge you to stay in regular contact with your diabetes team whilst embarking on any weight loss plan if taking any of the above medications.
How to lose weight
Number one on my weight loss list is consistency. This is something I see lacking in many patients. This patient demographic who lack consistency tend to have had success with weight loss in the past but have regained the weight usually with interest. One major cause of this is they lack consistency with their dietary habits.
For a weight loss plan to be successful long term, it needs to be forever. Therefore, the plan you decide to follow needs to be sustainable. Many patients I see adopt an all or nothing approach to dieting. They will completely abstain from the usual treats only to experience a relapse later. Therefore, I would recommend avoiding an all or nothing mindset.
This patient demographic jump between diets trapping them in an endless cycle of weight loss and weight gain. If a weight loss plan isn’t working for you, this isn’t time to abandon ship but rather time to steady the ship and build on the healthy behaviours you have already incorporated. This allows consistent progress to be made.
From my experience, those who have the greatest long term success are those who are able to stick with healthy eating principles most of the time whilst allowing for treats, parties, nights out etc some of the time. A good general principle to highlight this is the 80/20 rule. Follow healthy eating behaviours 80% of the time and it allows you to relax 20% of the time. How you do this is down to you. Perhaps you prefer a daily small treat or maybe you would rather a blow out at the weekend. Nonetheless, the important point here is if your diet plan is going to be a true lifestyle change it needs to account for nights out, treats, social events as these will inevitably be part of your life.
Be patient with this approach as it isn’t the trophy weight loss method but if you are consistent and stick with this approach you will lose weight and most importantly keep it off.
2. Weighing Frequency
Number two on my list is if you are weighing yourself regularly do not take much notice of the numbers week to week. One week is not enough time to reflect true weight loss. Allow me to give you an example. A patient attends a slimming club one week and loses 4 pounds. This tends to act as some motivation to keep going. The following week this individual returns for a weigh in and gains 3 pounds. They cannot understand how this has happened because they haven’t changed anything. If they see this pattern emerge over several weeks they tend to become disheartened and abandon the diet.
What this type of patient fails to realise is their week to week weight ins are not reflecting the true picture. They had not lost 4 pounds in week one nor had they gained 3 pounds in week two. The likelihood is they have remained weight stable or actually lost 1 pound overall. The body has so many factors that can mask true weight loss such as hydration or hormonal changes that week to week is not a good way of assessing true weight loss.
Try to allow some time between weigh ins such as a 1 month period. This allows enough time to pass to demonstrate what is really going on and is not prone to weekly fluctuations. Even if you do weigh in weekly, keep a closer eye on what the scales are saying between months.
3. Do not Yo Yo
Tying in with both the above points. Another typical behaviour I see with my weight management patients is they Yo Yo.
I mentioned this in point one regarding consistency but let me try to emphasis this point.
If you are not seeing the weight loss success you want to see this is not the time to quit and return to your previous behaviours because all that will do is guarantee you get the same results you have always had.
If your weight isn’t budging over a reasonable period of time (not just week to week) use this as feedback from your body that more lifestyle adjustments are required and act accordingly. I know it can be frustrating but in my experience when patients become disillusioned with their weight loss plan and revert back to the status quo they trap themselves in a cycle of one step forward and one step backwards.
4. Be honest with yourself
Unfortunately, regardless of the reasons why you can’t lose weight, ultimately from a biological perspective, if you eat less calories than your body requires you will begin to lose weight. I appreciate there are many reasons as to why this may be difficult or even impossible but from a pure weight loss perspective, this is the truth.
If your food supply was stopped today you would begin to lose weight. I understand there are often mitigating circumstances which make it very difficult to lose weight such as family commitments, co-morbidities, mobility issues etc and these are the issues I often discuss with patients in clinic.
I see many patients who report very reasonable diets in terms of nutrition and calorie intake but due to their individual circumstances they are not generating a sufficient calorie deficit. Everyone is different and therefore everyone needs to individualise their diet to themselves.
I therefore refer to my previous point that if the weight is not shifting do not take this personally but instead use it as feedback and identify areas where further changes can be made.
5. Too much of a healthy diet
When it comes to weight loss, the evidence has demonstrated many times the most important factor is the amount of kilocalories you are consuming. Every diet on the market achieves weight loss by inducing a negative energy balance requiring your body to use up it’s fat stores to help fuel your body’s daily activities.
Often I see patients who eat a very healthy diet but they just eat too much of it. It is possible to overeat with a healthy diet. In this instance reducing portion sizes or getting more active tend to be the solutions here.
6. Do not skip meals & 7. Organise yourself
I have put these two together because they relate directly to one another.
When I say do not skip meals I do not mean force feed yourself food you do not want. However, one very common trait I encounter with weight management patients is they skip meals. I suspect this leads to weight gain for 2 reasons.
First they may overeat at subsequent meals or snacks because they are hungry later. Second, skipping meals is a reflection on their lifestyle and often shows they are chaotic in how they organise themselves. They may eat on the run or put the family first only grabbing something if they have time. Inevitably they lose touch with what they are eating or choose higher energy foods because they are eating on the go.
Therefore, adding structure and routine into your day is absolutely necessarily in the vast majority of people to help with weight loss. The best way to do this is to ensure you have some variation of 2-3 meals per day or 3-5 smaller meals and snacks.
8. Be patient
This is crucial. Perhaps this is the conditioning of the weight loss industry where people want large weight loss figures week to week. A more sustainable approach is to change some baseline behaviours and stick with them. Over time the weight will come off and stay off.
I often see patients who tell me they are not losing weight but when I weigh them the figures demonstrate a loss from the last time I saw them. This is because they are not looking at the trend over time but instead the weekly figures. Therefore, if you consistent with your lifestyle change, be patient and the weight loss will follow.
9. The dietary advice
The dietary recommendations in type 2 diabetes are no different from generic healthy eating advice we provide to the general population.
As a rule the advice is very generic and needs to be tailored to suit the individual but if you follow the general principles it often translates into weight loss.
Point one: Portion control. Only eat to a point of satisfaction and not to a point of bloating.
Point two: Half the plate should be dedicated to vegetables or salad. This can be mixed into foods such as casseroles or stir fries and therefore does not have to strictly boiled vegetables.
Point three: A quarter of the plate should be dedicated to protein and the final quarter dedicated to starchy carbohydrate.
Point four: Minimise your intake of high sugar and high fat fats such as spreads, oils, cheese, fatty cuts of meat such as pork sausages, pies, pastry, chocolate, cakes, biscuits, sweets, sugary drinks and juices. This also includes eating out and takeaways.
Point five: Eat slowly. This can be helped by using smaller cutlery. You should take 15-20 minutes to finish a meal.
Point six: Eat low glycaemic index. I have provided a link over the words glycaemic index to explain what this is.
Point seven: Minimise your salt intake. Although not directly linked to weight loss we know diabetes can impact cardiovascular health. Having no more than 1tsp of added salt per day can help to lower/prevent increases in blood pressure.
Point eight: Aim for five portions of fruit and vegetables per day minimum. My recommendation would be to aim for 2 portions of fruit and 3 portions of vegetables. 1 portion of fruit is 2 small fruits or 1 medium fruit or half a larger fruit. 1 portion of vegetables is equivalent to 80g or approximately 4 heaped tablespoons.
Point nine: Aim for 2 portions of fish per week with one being oily. This provides you with your essential fatty acids your body requires.
Point ten: Minimise alcohol consumption. The guidelines for men and women in the UK is to not regularly consume more than 14 units of alcohol per week. Regularly consuming more than this can damage your health and also add many extra calories into your diet.
Point eleven: Stay hydrated. Often thirst can be mistaken for hunger. The guidance is to aim for around 2 litres of fluid (not just water) per day. Your urine is often a good indicator of hydration. If your urine is on the darker side, chances are you need to drink more fluid.
Point twelve: Eat more of low calorie nutritious foods to prevent hunger and excess calories being consumed. Higher calorie foods such as cheese, butter, full fat dairy, sugar, pastry, fatty cuts of meat etc do not allow for large portions to be consumed leaving you feeling hungry later or eating too many calories.
10. Physical Activity & Exercise
I have previously blogged on this subject in type 2 diabetes which I have copied below:
Many individuals I encounter with type 2 diabetes are or have been sedentary in their day to day life. I would define sedentary as walking less than 5000 steps per day with no, little or very low intensity formal exercise.
This becomes significant because activity levels of this scale are the perfect breading ground for weight gain, the predominant factor in type 2 diabetes.
Those who lose their ability to or do not conduct regular physical activity have a very small margin of error when it comes to diet. I speak with countless patients who swear blind they do not eat large amounts. However, because of their low activity levels they are not using up the energy they are ingesting. Unfortunately, that energy has to go somewhere, and if it is not used up as fuel it will be stored as fat and thus contributes further to their diabetes progression.
This can be very frustrating for the patient. If activity levels are low then weight loss to improve their management of their type 2 diabetes must come through dietary means.
I have patients reporting a daily kilocalorie intake of 1200-1500kcal per day and still struggle to lose weight. Perhaps there is an element of under reporting going on and the evidence would suggest people typically underestimate their energy intake by approximately 20-25%. However, if they are accurate and eating very small amounts, it is very difficult to identify further areas in the diet which may induce weight loss without eating only vegetables.
Therefore, if you identify as someone who has very limited amounts of physical activity my first suggestion would be exploring where additional activity could be incorporated into your day. Perhaps this is using old cliches such as parking further away from your destination but can be as simple as pacing around when you are on the phone. Literally every little counts. Perhaps you can find more obvious gaps in your day and schedule in a daily walk to try to increase your steps.
The governments guidelines as a minimum amount of physical activity is to achieve 150 minutes per week or 30 minutes per day 5 times per week at a moderate intensity. This can also be accumulated via 10 minute blocks. Moderate intensity is defined as any activity which gets the heart beating faster and makes you feel slightly warmer. You are however still able to hold a conversion.
If the activity is vigorous and thus high intensity this can be reduced to 75 minutes per week. Here you will be unable to hold a conversation and will noticeably be out of your comfort zone.
Both these recommendations should include a combination of resistance and aerobic activity.
Keep in mind, these recommendations are the bare minimum and are for improving health and reducing the risk of lifestyle related diseases such as cardiovascular problems, diabetes, dementia, osteoporosis etc.
For weight loss, you will need to increase this to around 1 hour per day of physical activity. This tends to equate to around 10,000 steps but theres no golden rule with this. With vigorous activity the time spent doing activity can be reduced but again the guidelines focus on calorie reduction aiming to achieve somewhere between 500-600kcal reduction per day either through diet, activity or a combination of both.
It is always a good idea to quantify your activity levels and therefore using the step tracker on your smart phone or wearable device is a really good starting point.
Exercise, as mentioned for the purpose of todays article, will focus on more purposeful activities such as sport or attending the gym. This generally is performed at higher intensities than seen with day to day life activities.
There are various forms of exercise. Cardiovascular work (known commonly as cardio) is performed at moderate intensities and primarily trains the heart and cardiovascular system through repeated mechanical motions such as running or swimming.
Resistance training is concerned with strengthening exercise such as weight lifting and is good for muscular strength and bone health.
Mobility and flexibility includes activities such as yoga where the focus is on lengthening muscles.
Anaerobic exercise is very high intensity activities such as sprinting or circuits. This will take you out of your comfort zone and can cause physical distress whilst performing the activity.
In reality, most forms of exercise incorporate a combination of all these types of exercise but generally one type is predominant.
Contrary to popular belief, exercise has not been found in the literature as an effective weight loss method. This could be because for the vast majority of people exercise takes up a very small proportion of the week leaving many more hours to undo the good work. It may also be because exercise lures people into a false sense of security with their dietary choices believing they can eat more than they have actually expended during exercise.
Whatever the reason, the results of inactivity is something I see transparently in practice very regularly. How much you need to do varies from individual to individual because each different person will perform differing amounts of exercise, at different intensities at different frequencies. For example, someone running 5 times per week with a running club, at varying intensities will likely see very different results from someone attending a Zumba class twice weekly.
Conducting regular physical activity is without doubt a beneficial endeavour. Those who do participate regularly at good intensities do see results and improve their diabetes control. We shouldn’t also forget the health benefits associated with regular exercise.
An ideal would be to combine regular physical activity with exercise but in todays modern society many jobs make this difficult.
I hope this has given you some practical insight into the types of problems my patients encounter with type 2 diabetes and weight loss.
Notice how my first 8 points in the article did not even mention food. This is because it is more a mindset with weight loss. Many people know what healthy eating looks like but it is their mindset and conditioning which prevents them sticking to a long term lifestyle change.
Remember, if you want long lasting weight loss success, your lifestyle change needs to be forever.