Contributor: Dr. Staci-Marie Norman, PharmD, DCES

Have you ever tried to lose weight? Ok, I can see your eyes rolling, hands flying in the air – the better question may be, who hasn’t tried to lose weight? Are you always looking to lose a few extra pounds like I am? (To be honest, after COVID and two years of only wearing scrubs, a few is an extra 20). My Facebook feed always seems to have the latest and greatest, the easiest magic pill that will melt the fat right off you in a matter of days. Oh, how I wish this were true! The person who comes up with that magic pill will be richer than Jeff Bezos. But in reality, there is no magic pill, and truth be told, you need to be very careful of some diet methods, especially when trying to lose weight with diabetes.

Let's start with the basics of weight loss. It's a simple equation: calories in have to be less than calories out to lose weight. This can be done by cutting calories in the foods you consume, increasing the amount of energy you expend through activity, or a combination of both. The goal is to decrease your total calories by 500 to 700 calories per day. One pound of weight equals 3500 calories, so technically, you should lose one pound per week if you reduce calories by 500 per day. I feel your eyes rolling again! Just one pound? I need to lose 10 pounds by the weekend! Yes, I've been there too, but the cold hard truth is that one to two pounds of weight loss per week is healthy weight loss. More than that typically doesn't last and can be dangerous.

Do you remember the TV show "The Biggest Loser?" I must admit I loved seeing the contestants "melt" seemingly before our eyes. They would have 5, 10, 15, even 20 pounds of weight loss in the first week! Did you ever notice that this rate never kept up? There were usually much lower amounts of weight loss in the second week, although often more than the 1-2 pounds per week that is normal. There are a few reasons for this:

1. Water loss - When you start a diet, you have probably noticed that in the first week, you may lose close to 5 pounds. But the next week, you might only lose a pound or two. When we start eating healthier, we typically get rid of excess sodium and start drinking more water. This helps us shift and excrete retained fluids. But the fluid "equilibrium" is quick to normalize, and from there on out, we are losing (hopefully) mainly fat and not fluid. To lose fat, we need to burn fat, which is much more difficult because fat is our body's defense mechanism against starvation!
2. Daily Calories - When looking at the large drops in weight on "The Biggest Loser," we need to consider the number of calories the contestants were allowed. The typical daily calories eaten by contestants were 800 to 1200. When their eating habits before coming to the show were evaluated, most were eating 5000+ calories per day. Think about that deficit - almost 3500 calories per day if they had been eating 5000 calories before starting the show! That's a pound per day!
3. Exercise - We saw the "last chance workouts," but the contestants did that for multiple hours every day to increase their calorie expenditure. And for full disclosure, medical professionals lived with the contestants, making sure they were physically okay through the whole show.

With this background information, maybe we should reset our weight loss expectations. I know it seems like those 10 (or 20) pounds made their way to our bodies overnight, but it does take some time to gain weight. And unfortunately, it also takes time to lose weight. And, more importantly, to lose weight safely.

It’s hard enough to lose weight, but then add living with diabetes, and things become more complicated. A “starvation” type diet is not healthy, and it can be extremely dangerous depending on the types of medications you might be taking to manage your blood glucose. If you take a sulfonylurea (glyburide, glipizide, glimepiride) or take insulin, you can put yourself at high risk of hypoglycemia when dieting. These medications either stimulate more insulin to be released or physically increase the amount of insulin in your body. And once you take them, you can’t get them back if you decide to skip a few meals. Even if your blood glucose is at target or heading toward hypoglycemia, they keep working. There must be glucose in the body from food to avoid a hypoglycemic event. The safer way to lose weight, especially with these medications being used for glucose management, is to eat smaller portions throughout the day so that your blood glucose never dips too low. As you lose weight, you might even find that the medications will need to be adjusted lower to keep you from having hypoglycemic episodes – I’d call that a win, win!

There are some blood glucose medications that can lower your glucose levels and may also help you lose weight. One such medication is the GLP-1 or incretin mimetics. I'm sure you have seen the commercials on TV for Victoza, Ozempic, Trulicity, and Rybelsus, to name a few. These work to lower blood glucose levels by acting like our body's own incretin hormones that the gut produces when food is eaten but can be diminished with diabetes. These hormones signal the pancreas to release insulin to handle the glucose from food and stimulate stomach motility or churning. With diabetes, the stomach's motility is much faster than expected because of the decreased amount of incretin hormones produced so food can pass through the stomach and into the small intestines within 20 to 30 minutes versus 60 to 90 minutes. This can lead to increased hunger or never feeling full, so overeating is easier. By slowing down this motility, the stomach stays full longer, and you feel full longer. However, you must be conscious of decreasing your portion sizes because nausea and vomiting can become a very real side effect if you overfill your stomach. This drug class is so effective in lowering blood glucose and helping people lose weight that it is being used as weight loss therapy for people without diabetes.

The second family of medications that can lower blood glucose and weight is SGLT-2 inhibitors. Some commonly seen in TV commercials include Invokana, Farxiga, and Jardiance. These work to lower the threshold of glucose reabsorption in the kidney. Usually, the kidneys will start to “spill” glucose into the urine when the blood glucose is 180 mg/dL or higher. These medications lower that threshold to 130 mg/dL. This lowers blood glucose and can cause weight loss because the glucose lost in the urine is also calories lost through the urine. Sodium is also lost, taking water with it, which can lower the blood pressure. Therefore, you might see some of these medications advertised for heart failure and not diabetes! They have been found highly effective in lowering the risk of heart failure AND kidney disease complications! Win, Win, Win!

Even though these medications are helpful in weight loss, they cannot do it alone. Healthy eating, portion control, and exercise always must be part of the plan.

Dr. Staci-Marie Norman, PharmD, DCES received her bachelors from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.