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Dear Dr. Roach: I am a 67-year-old woman with Type 2 diabetes. I take 1,000 milligrams of metformin twice a day. My last A1C was 8.1. I desperately want to lose weight to get rid of the diabetes or at least lower the A1C, and am cutting down on carbs, but I am told it is very difficult to lose weight on diabetes meds. Can you explain why, and offer any wight-loss advice?

R.P.

Dear R.P.: It can be harder to lose weight with Type 2 diabetes. The underlying defect is resistance to insulin, so blood insulin levels usually are high. Insulin is a growth hormone, a signal in the body that there is plenty of sugar and that the body should store energy as fat.

Medications for Type 2 diabetes that increase insulin levels tend to make it even more difficult to lose weight. Insulin itself, and medications that tell the pancreas to make more insulin, such as glyburide, tend to promote weight gain.

On the other hand, medicines that reduce insulin levels tend to promote weight loss. Metformin works mostly by preventing the liver from making sugar, so the body’s own insulin can work more effectively on the sugar we take in through food. Another medicine, exenatide (Byetta), promotes weight loss in some people. Other medications for Type 2 diabetes have variable effects on weight.

Of course, controlling total calorie intake, especially carbohydrate intake, has a powerful effect on weight, both directly and indirectly. Similarly, exercise makes insulin work better, so modest changes in diet and exercise, along with careful attention to the choice of diabetes medication, can help promote weight loss. I have found that exercising a half-hour or so after eating seems to work well.

Dear Dr. Roach: My son is 53, and three years ago he had three stents put in due to clogged arteries. His cardiologist put him on Lipitor at 80 mg. I don’t know if this is necessary.

J.K.

Dear J.K.: In people with blockages in the arteries in their hearts, there is really no doubt that medications like atorvastatin (Lipitor), a statin drug, reduce the risk of heart attack. Although they can have side effects, for most people the benefit far outweighs the risks.

It’s important to recall that even a powerful medication like a statin can’t optimally treat people if they don’t treat themselves right. Years ago, I had a patient who was doing well after his bypass surgery and was taking a statin with good results. Walking through the hospital cafeteria, I saw him eating a triple cheeseburger (why the cafeteria even sold such a thing is a separate question), and he sheepishly argued that he was taking his statin. A statin can’t beat a triple cheeseburger.

Good cardiac health requires a good diet of mostly plants, with whole grains, nuts, fruits and fish included for people who choose it. Exercise an important part of the treatment, and walking is nearly as good as any exercise. Medication is just a small part of a healthy lifestyle and preventing heart disease, which, although rates are decreasing, is still the leading cause of death in industrialized countries.

Email questions to ToYourGoodHealth@med.cornell.edu.

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