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If there's a "fat gene", then I've got it...

Photograph by Ladislav Jirousek, from the book L'udovy oden na Spisi, compiled by Dr. Stanislav Prochotsky.
© Okresny narody vybor v Spisske Novej Vsi

Losing Weight in the DPP

For the past year and a half, I have been a research subject in a long-term study aimed at preventing the onset of Type 2 diabetes. As a member of the "Lifestyle" group, I have been encouraged to exercise and lose weight, and have lost over 50 pounds so far. In this section, I'll tell you about the diabetes study, and about the techniques I have used to successfully lose weight.

What is Type 2 Diabetes?

Diabetes is a disease in which your body is unable to properly use and store glucose (a form of sugar). Glucose backs up in the bloodstream - causing your blood glucose or "sugar" to rise too high. There are two major types of diabetes. In Type 1 (also called juvenile-onset or insulin-dependent) diabetes, your body completely stops producing any insulin, a hormone that enables your body to use glucose found in foods for energy. People with Type 1 diabetes must take daily insulin injections to survive. This form of diabetes usually develops in children or young adults, but can occur at any age.

In Type 2 (also called adult-onset or non insulin-dependent) diabetes, the body may produce insulin, but the body might not use it properly to convert food into energy. This form of diabetes usually occurs in people who are over 40, overweight, and have a family history of diabetes. Type 2 diabetes is the most common type of diabetes, yet we still do not understand it very well.

People who develope diabetes may experience certain symptoms, such as excessive thirst, frequent urination, weight loss, increased hunger, blurry vision, infections, fatigue, or wounds that don't heal. But in many cases, there are no symptoms, especially with type 2 diabetes, which tends to come on gradually. People with type 2 diabetes can live for months, even years without knowing they have the disease.

Undetected or poorly managed diabetes can lead to a host of long-term complications - among them are heart attacks, strokes, blindness, kidney failure, blood vessel disease that requires an amputation, nerve damage, and impotence in men. But happily, a recent nationwide study completed over a 10-year period showed that if people with type 1 diabetes keep their blood sugars as close to normal as possible, they can reduce their risk of developing some of these complications by 50 percent or more.

For more information on diabetes, see the Joslin Diabetes Center Fact Page.

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The Diabetes Prevention Program

The Diabetes Prevention Program is a 6-year nationwide research study to see if type 2 diabetes can be prevented. The study is following a large number of people who are at risk for type 2 diabetes. Some of the subjects are being given a medication that is currently used for treating type 2 diabetes, some are being asked to modify their lifestyle to exercise more and lose weight, and others, are in a control group and are not doing anything differently. At the end of the study, the groups will be compared to see how many people in each group have gone on to develop diabetes.

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How I Got Involved

I became interested in the DPP because I believed I was at risk for type 2 diabetes. My father currently has it, and my grandmother on my mother's side also had it. In addition, I was female, over 40, and overweight. So I seemed like a likely bet.

I first heard about the program through an article in the Boston Globe. At first I didn't do anything about it, but later I received a mailing inviting me to a screening and information session at the Joslin Diabetes Center one Saturday morning, so I decided to go.

In addition to the risk factors I mentioned, the program was looking for people who have "impaired glucose tolerance". That means that their blood has more sugar in it than normal, but not as much as diabetes. To determine this, they need to take a blood sample after you have been fasting for 12 hours. At the first visit they did a quick screening test and found that I potentially fell within the parameters they were looking for. They then invited me to come back for a more involved "glucose tolerance test". In the glucose tolerance test, they first take a fasting blood sample, then have you drink a concentrated glucose solution, and then take two more blood samples 30 minutes and 2 hours later.

The results of my first glucose tolerance test were borderline. I was in the range for the 2-hour blood sugar level, but under the desired range for the fasting blood sugar level. So I did not meet the criteria for the study. But they invited me to come back after 6 months and repeat the test. The second time, both results fell just within the guidelines.

Before actually signing up for the study, I had to go through a battery of additional tests, including a physical exam and an ECG, and had to fill out a bunch of questionnaires to assess my eating habits and emotional stability. I was asked if I expected to stay in the Boston area until 2002 and if I planned to get pregnant (which would mess up the study). I had to report on any medications I was taking that might interact with the study drugs, and I got weighed and measured in every dimension.

In addition, I had to spend three weeks going through the routine I would be asked to follow if I were actually in the study. At this point, we didn't know yet what group I would be assigned to (that is done randomly, of course), so I had to take the placebo pills on a daily basis, and also to fill out a diary of my eating and exercise. I also was given an 8-page informed consent form to read and study before the time came to sign on the dotted line.

All in all, it took nearly a year from my first contact with Joslin in September, 1997, to my acceptance into the program in June, 1998.

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Why I Decided to Sign Up

After going through the dry run and reading the consent form, it was clear that participating in the experiment would be a little bit of a hassle. If I was assigned to either the medication group or the control group, I would have to take a pill twice a day. (They don't want you to know which group you are in, so the control group gets a placebo to take.) I would also have to come in several times during the first few months for blood tests to ensure that the drug was not affecting my liver function.

If I got assigned to the diet and exercise group, I would be asked to lose 7% of my body weight, and to exercise regularly. I would have to come in and meet with a "lifestyle coach" 16 times in the first 6 months, and then every two months thereafter. They would also offer exercise classes twice a week, and other classes to assist me in meeting the diet and exercise goals.

In either group, I would have to come in for fairly extensive medical tests every 6 months.

The study would pay me $150/year for my participation. In addition, they would cover my parking costs for all of my visits. (They'd already been comping my parking for all of the screening visits.)

I read the consent form pretty carefully, and came to my next visit with a set of questions all prepared. They seemed a little surprised at this (I guess most people aren't quite so organized), but they were happy to take the time to answer all of my questions.

One of the things I was concerned about was the safety of the medications. Originally the study included two different drugs: metformin and troglitazone. Metformin, also known as glucophage, is a drug that has been in use for treating type 2 diabetes for many years. (It is the same drug that my father is taking.) It has a pretty good history of safety. The second drug was a little more uncertain. It was a fairly new drug which had only been in use for a few years, and there were some disturbing reports of liver damage in some people who had been taking it. That was part of the reason the DPP was scheduling frequent liver function tests for people in the medication group.

As it turned out, right around the time I was going through my dry run, it was decided to remove troglitazone from the study. The evidence for liver damage became just too great to justify using the drug in a preventive role. So there was a bit of a delay as they reorganized the study into three groups instead of the original 4. But I was relieved that I didn't have to worry about getting that particular drug. (Troglitazone, under the brand name Rezulin, continued to be used for treating type 2 diabetes for another 2 years, but was removed from the market in March, 2000.)

I had mixed feelings about the lifestyle group. I was getting close to 200 pounds in weight, and I really felt it was time for me to do something about it. At the same time, I had tried to lose weight before, with only moderate success. So I wasn't sure I could do it. Still, it would be nice to have the help.

So there were potential benefits to me. If I got in the lifestyle group, I would probably lose weight. In either the lifestyle or medication group I might improve my chances of not getting diabetes. And even in the control group I knew I would be monitored carefully.

But I think what finally convinced me to enter the study was the chance to do something good for other people. I am really convinced that diabetes is going to a bigger problem in the coming years, as the baby boomer population ages. We all know that people are more and more overweight these days, and I am sure that this will have bad effects on our health in general, and in the prevalence of diabetes in particular. So I thought I could do my little bit to try to improve the situation.

As luck would have it, the computer assigned me to the lifestyle group.

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Being in the Lifestyle Group

As I member of the lifestyle group, I was assigned to meet regularly with a nutritionist, Sharon Jackson, who would serve as my coach. We were to meet weekly for the first 8 weeks, then biweekly thereafter. At each session, I weighed in, then Sharon gave me a short lesson plan to work through with her. I also got a Fat Counter booklet listing the fat content of 1500 foods, a pile of little blue notebooks where I would record my eating and exercise, and a chart I could use to keep track of my progress. I also got a bunch of gifts, like a water bottle, a kitchen scale, and so forth.

I explained to Sharon my doubts about my ability to lose weight. I told her that I had tried before, with some success, but I'd gained it all back. And I had already changed my eating habits quite a bit, cutting back on fatty meats, eating cereal with skim milk for breakfast, and generally trying to avoid fat. So I didn't see what more I could do.

Sharon asked me to just hang in and try out the program and see how it went.

There were two goals for the participants of the lifestyle program. The first was to lose 7% of your weight through healthy eating. For me, that meant going from 196 to 182 pounds or less. The second goal was to do 2 1/2 hours of brisk, physical activity each week.

Previous research had shown that leaner and more active people are less likely to get diabetes. A moderate weight loss and physical activity have been shown to improve the body's use of insulin. (In addition, losing weight and being active has also been shown to lower blood pressure and improve cholesterol levels.)

Each of the sessions with Sharon focussed on a different area of the process, from factual issues, such as how to determine portion sizes and the amount of fat in food, to psychological issues such as "Take Charge of What's Around You" and "Talk Back to Negative Thoughts". But in addition to the prepared material, Sharon was always ready to talk about whatever problems or issues I wanted to talk about, and to encourage me in my small successes. She was great!

The chief focus of the healthy eating portion of the plan was to cut down the fat in the foods I ate. I was given a goal of 42 grams of fat a day, and I had to write down everything I ate, calculate the fat grams, and add them up each day. I have to admit that writing down everything I ate was a big pain, but I think it was an essential part of the program. By writing everything down, I couldn't play games with myself and pretend I was eating less than I actually was. And by seeing what the fat content of each food was, I could make intelligent tradeoffs. For example, I love ice cream, but the 12 grams of fat in 1/2 cup of premium ice cream just used up too much of my daily allowance. So I had to make ice cream an occasional treat, rather than a daily indulgence.

The first few weeks were the hardest. I still had a craving for fatty foods, so even though I never had to go hungry, I still felt that something was missing. And it was hard to get out and exercise because I was so heavy, and my body ached after each session. But after about 6 weeks, things started to get easier. I got more accustomed to eating low-fat foods, and my body stopped craving the higher-fat items. In fact, after a while, I found that I actually couldn't eat high fat foods without quickly feeling sated and overfull. And the exercise got easier as my legs got stronger and I started losing weight.

Nothing much happened in the first four weeks - I dropped only 2 pounds and started to feel discouraged. But then, much to my amazement, I started dropping at a rate of about a pound a week, and hit my goal weight after only 4 months. At that point, I was all fired up, and motivated to continue and see how far I could go. After 6 months I'd lost 25 pounds, after a year I'd lost 45 pounds, and right now I'm hovering around 55 pounds lost.

At this point, I believe that I have made permanent changes in my behavior in regard to food and exercise, and I am absolutely convinced that I will never be fat again. Ladies in the fields

I'd like to explain about that picture on the top of this web page. Shortly after I started meeting with Sharon, my father took his first trip to Slovakia to track down long-lost relatives. He brought back a couple of picture books, and that particular picture struck me. These were women who obviously were working hard in the fields, and yet they all shared a stocky body type - the same body type that my grandmothers had, and the same body type that I was trying to shed. I took a copy of the picture in to Sharon and told her that this was the gene pool that I had come from, and this was what I had to fight against. Sharon told me that genes were not destiny and I would be able to overcome my genes. And she was right.

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Good Things about Losing Weight

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Bad Things about Losing Weight

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Tips for Losing Weight

I'd like to share with you the things that worked for me as I went through this weight-loss process. And I'd like to make the point that these things are not just my personal opinions. There is a national study going on, called the National Weight Control Registry, which is a large database of people that have successfully lost 30 pounds or more and kept it off for more than a year. The experiences reported by these people agree in almost every respect to the things I have concluded about weight loss.

If you are trying to lose weight, I hope my story has convinced you that it can be done, and I hope some of my tips will be helpful to you. I wish you the best of luck!

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An Update

This article was originally written in 2000. The DPP was originally scheduled to run until 2002, but the results were so successful that it ended one year early. The diet and lifestyle group showed a 58% reduction in the incidence of diabetes! The medication group also showed an improvement, although not such a dramatic one. Read the press release here.

Most of the people in the original DPP have continued into another 5-year DPP follow on study. For this study, we only have to go in for testing twice a year, although we are invited to occasional programs to keep us all interested and involved.

Over the past 5 years, I have gained back a little of the weight I lost, but I'm still down about 45 pounds from my all-time high. I'm now a proud member of the National Weight Control Registry, a study of people who have successfully lost weight and who have kept it off.

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The Obligatory Before and After Photos

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