Happy Saturday! You may experience a little deja vu on this one, as it's a topic we addressed back in December 2011... about dealing with weight struggles.

Got the dieting blues on these Weighty Matters? We hear you. Please take a gander at this week's edition of Ask D'Mine, hosted by veteran type 1, diabetes author and community educator Wil Dubois.

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

 

Tim from Washington, type 1, writes:  My question is a little more nuanced than "does insulin make me gain weight?" I'm a type 1 diabetic, diagnosed in June of 2009. At the time of my diagnosis, I was 149 pounds (on a 6'3" frame). I took Lantus from the beginning, but have only started taking Novolog over the past 10 months, because oral meds were still working. Since I've been taking Novolog, I've gone off Metformin and Glimepiride. I've slowly but steadily been gaining weight ever since. I have never EVER been able to gain weight in my life. It's getting out of hand and exercise (and diet) alone are really doing nothing. Is it possible that I'm insulin resistant and this is making me pile on the pounds? Is it possible to have insulin resistance as well as being type 1?

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But wait! There's more!

Tim from Washington, type 1, writes again, asking:  Forgot to ask, perhaps I need to be taking something like Symlin? Do many type 1s use this? Am I strange for needing it?

  Wil@Ask D'Mine answers: Humpty-Dumpty sat on a wall... Wow. There are so many pieces to cover here, I don't know which piece of All the Kings Men and I should pick up and run with first. I guess we'll start at the beginning, at your diagnosis. So, for all of you T1s out there who were diagnosed as kiddos, you need to know that the adult diagnosis experience is different—on a physiological level. The destruction of the insulin-producing beta cells in the pancreas takes place in slow motion, opening the door for the effective use of oral meds, at least for a time.

So don't go flaming poor Tim in comments telling him he's a misdiagnosed type 2.

Now I'm going to talk about the various meds — from the perspective an educator who works with three docs and who's seen many PWDs try many things. (Disclaimer: Remember that I'm not a doctor, nor am I playing doctor, either. I'm just sharing some opinions and experience that may help.)

So... Glimepiride would be my last choice of oral medication for someone whose beta cells are being wiped out by his immune system. Glimepiride forces the body to over-produce insulin. In type 2s, it's suspected of hastening insulin dependence. So... umm... well, to my way of thinking, if your body is bound and determined to kill off your beta cells, I don't think we should be giving it pills that hasten the process. But that's just me. And again, I'm not a doctor, so what do I know?

Metformin, on the other hand, makes some sense to me. Along with its other properties, it's a mild insulin sensitizer, so it would help your body make the most of what it had left while it still had it.

Now, as to your recent weight problems, I have a theory: the Glimepiride tends to make people gain weight. The Lantus makes some people gain wait, but doesn't affect others. The Metformin is officially weight neutral, but shaves some weight off a lot of people. The entire soup you were on was likely weight neutral; with the Met's weight-sparing effects balancing out the Glimepiride and Lantus.

Then enter Novolog. Like Lantus, the Novolog makes some people pack on some pounds. At the time you started it, you also stopped the Metformin, which was the only potential weight-reducing prescription in your medicine cabinet. And that's when you started gaining weight. Hmmmmm... It seems we have a pretty good circumstantial case for the cause of your weight gain here. You could ask your doc about re-starting the Met and see what happens.

Now, as to insulin resistance. You asked if you could have both type 1 diabetes and insulin resistance. You bet your Novolog you can! Anyone can have insulin resistance. But insulin resistance doesn't cause weight gain. The two go hand-in-hand but you've got the relationship backwards. The more you weigh, the higher your insulin resistance will be. And then of course, the higher the insulin resistance is, the more insulin you need. And of course, if you believe that insulin causes weight gain all by itself (and I'm not convinced it does), then the more insulin you use the more weight you will gain, which will give you more insulin resistance, which...

Well, you get the idea. The tiger is chasing its tail here. So anything is possible, but I don't think that new onset insulin resistance could be a singular cause of weight gain.

But what to do? Is Symlin the answer? Maybe. But not the only answer, and Symlin may not do what I think you think it does. Read on.

Symlin isn't really an anti-insulin-resistance drug, like a TZD, although it does reduce your insulin needs. Symlin is a synthetic version of the hormone Amylin, a natural pancreatic islet peptide that's normally secreted by your body along with insulin at meals. Yep. Amylin is insulin's neighbor. And like insulin, in type 1s, Amylin goes missing in action.

Amylin's job? It helps turn off the liver's sugar production, slows down the stomach, and signals the brain when you are full. Sound familiar? Yep. Same job description as GLP-1, the gut hormone of Byetta and Victoza fame.

Since early on, Symlin's been approved for use by type 1s (as well as insulin-shooting type 2s), leading some people to call it "the Type 1 Byetta." It doesn't do that much for A1C lowering (adding it will buy you a half-point drop), but it does help level out post meal blood sugar spikes; and it's a kick-butt weight loss drug.

What? Oh. Of course it's not approved for weight loss! What I meant to say is that as an unintended side effect, it's associated with some kick-butt weight loss. It does so like its GLP-1 cousins, not by magically melting fat, but like this: people who use Symlin find they are less hungry because their stomachs are emptying more slowly and their brains are getting the full stomach signals: both of which result in less eating and therefore less calorie consumption. If the calorie intake is less than the calories burned, you lose weight.

You asked if Symlin is used by type 1s. Yes. Yes it is. In fact, it's mainly used by type 1s.

When it's used at all.

The reason I say this is that very few people who start Symlin stick with it. That's because it's a pain in the ass to use. As a type 1 Symlin user, you'd need to take two shots with every meal, one of insulin and one of Symlin. Or, if you use a fancy high-tech insulin pump, you have to take insulin via your pump and then your Symlin via shot. For the first couple of years, Symlin was only available in vials, making this even worse. Pump and syringe. That's like being armed with a laser gun and a stone knife. Symlin is now in pens, too, so this isn't quite so ridiculous, but I think you can see where this is going. Long-term "compliance" with Symlin is pretty poor. It's just too much work.

That said, I do know one guy, who for a time liked Symlin so much he wore two pumps: his current one with insulin and his old one with Symlin. But then one day he got them mixed up. It ended badly, but thankfully, he's still alive.

Still, if your doc agrees, I see no harm in trying Symlin. You'll likely need to reduce your Novolog by 50% when you start out.

But, additionally, Byetta—and now Victoza—have both been approved for use with insulin, so you can also give either of those a try, too. I'd even say that either of these two GLP-1 meds might be a better choice as, unlike Symlin, they work in a glucose-dependent manner. That means they pretty much shut themselves off when your sugar normalizes, while Symlin is associated with hypos that kick like a mule.

Infinitely variable, constantly challenging, diabetes itself is nothing if not strange. But, no, Tim, you would not be strange for needing Symlin.

 

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.
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