PCOS Part 1 - I Looked at Bread the Wrong Way and Gained 5 lbs
There are many sources on the web that talk about period stuff, so I’m not goint to start there in what will likely be an infinite number of blog posts about PCOS. I’m going to start with the interaction between the metabolic endocrine system, insulin resistance and carbohydrates.
To start, what is a carbohydrate? One of three main sources of nutrients of which the basic component is glucose. This includes sugars, starches (chains of sugar) and fiber (chains of sugar arranged in a complex fashion that make them difficult to break down). There are the obvious carbs - candies, sweets, cookies, bread, rice and pasta, but also fibers found in vegetables, fruits and whole grains. Many things that we think of as healthy (especially if you grew up with the food pyramid) like milk and baked potatos are full of carbs.
Carbohydrates are not in and of themselves bad or evil. In fact, they are one of only two things the brain can use as food - the other is ketones formed from breaking down fats. The problem with carbohydrates is how they interact with the rest of the body and your metabolism as a whole. Back in the day (and the day being sometime in the last 100 million years maybe) we developed insulin as a way to help us store excess carbohydrates from when times are good to be used when times are lean. This was a brilliant system when starvation was one of the biggest risks we humans faced. But then, we learned how to farm. The development of agriculture suddenly meant that our bodies were eating less meats and wild berries and more breads and their ancient storage form - beer. Suddenly we get obesity for the first time. Yields were still meager and the work was hard (and life generally), so obesity was rare outside of the most upper class people. When did things really change? Not until we really started to divorce carbs from fiber in the form of simple sugars that exploded after World War 2. The other major offender, and one that absolutely must be dealt with is that we grew so much corn we had to find a use for all of it and the solution was high fructose corn syrup.
So, what happens when we consume carbohydrates? When our body tastes sweetness, the pancreas gets a message that it’s time to get going. As blood sugar starts to increase as carbs are absorbed from the intestines, the pancreas starts to release insulin to keep blood sugar in the normal range of 80-120. Insulin then causes the sugars to be taken up by numerous body tissues like the liver and muscle where it is turned into a storage form called glycogen, fat cells where sugars are enzymatically converted to fats, prevents fats from being broken down to be used for energy and then goes to the brain where it impacts hunger symptoms. In a person with the average metabolism, as the sugar levels come down, the insulin is quickly metabolized away and the body goes back to its baseline energy balance of then slowly releasing fats and sugars back into the blood stream to keep the body going.
Now, how does this look in someone who has insulin resistance? It takes a little longer to get the insulin released, so blood sugars spike immediately after eating and then there is a large overproduction of insulin. The insulin then does all of the above things, but does it on a larger scale. This means every bit of glucose is getting turned into fat, the liver is stuffed so full of glycogen it has trouble doing other things (the misnamed “fatty liver”), the brain can’t figure out what to do with itself and as glucose starts to fall, but ketones can’t be released from fat cells, so you get brain fog and very strong carbohydrate cravings and overall, you feel miserable. Then, when blood sugars start to drop precipitously, the body goes into a fight or flight mode and starts releasing cortisol to deal with all of these problems. Cortisol is a stress hormone that then floods the body with glucose and we start repeating the cycle again. The result though is weight gain and fatigue.
Whats the deal with high fructose corn syrup (HFCS)?
One of the “simple” sugars we frequently encounter is sucrose and it is a combination of a glucose and a fructose molecule arranged in a 1:1 fashion. Fructose is metabolized differently by the body in what we think originally was a bypass to help us survive in starvation events. Fructose can go straight in to energy generation (or fat creation if the body isn’t in a starvation situation) with no negative feedback on hunger and no significant control mechanisms. So, if we increase the fructose percentage, it’s like red bull for fat generation. HFCS also has a sweeter taste than glucose and that drives increased carbohydrate cravings. In other word, it’s like mainlining diabetes. There is very likely no worse substance we could be exposed to that is making us sicker and making people gain weight. HFCS can also induce insulin resistance because it isn’t regulated by the insulin system. No matter what’s going on with insulin levels in the body, if there is fructose, its just getting poured into the blood stream as excess energy.
Can insulin resistance be reversed?
We don’t think so. This is still an area where more research is needed, but given what we know about the metabolism of people who have been overweight and are now a normal body weight, probably not. It’s something that just has to be managed. The good news is that it can be managed. The bad news is that it has to largely be managed by changing our diet and getting the carbs out. If you love carbs and crave them and feel like you can’t live without them, but then feel terrible after eating them, you aren’t a bad person. You are a person with insulin resistance. The body’s carbohydrate cravings are very real and very powerful. After all, these systems were developed to keep us from starving to death, so they can’t be mild. They are second in power only to our drive to reproduce.
How can insulin resistance be managed?
Don’t eat carbs … ever. There is no such thing as an essential carbohydrate. There are essential amino acids and essential fatty acids. There is no reason why we need to eat carbs. Admittedly, the transition from a carbohydrate diet to a no carbohydrate diet is unpleasant. I have lots of tips, but as a long time lover of carbs, I get how hard it is and make no pretense that this is an easy transition.
Don’t eat carbs … most of the time. What do I mean? Extreme limits on carbohydrate consumption - to say one meal a day and at that one meal, limit to 30-50gm. Even then, simple sugars should be out and you probably don’t need to ask my opinion of high-fructose corn syrup if you have read this far. Any carbs contained in a green veggies don’t count.
Metformin - A lot of poeple think of this as a diabetes drug, but it’s actually our number one weapon against insulin resistance in the medication space. It works three ways. It prevents the formation of new glucose molecules in the liver (gluconeogenesis), decreases peripheral insulin resistance and blocks the absorption of some carbohydrates from the gut. That last one also causes it’s number one side effect - GI distress. You can lessen this with medication timing and by avoiding excess carbs - especially excess carbs with fats. It has the benefit of not causing low blood sugar or hypoglycemia.
GLP-1s - The newest (and priciest) kid on the market - these drugs work by:
improving insulin release from the pancreas so blood sugar never has a chance to skyrocket.
inhibit the release of glucagon (it’s actions are the flip side of insulin) so excess glucose isn’t being released into the blood from the liver.
stops hunger cravings and creates a sense of satiety. This is one of it’s most powerful mechanisms because you don’t feel hungry at all while taking these drugs.
slows gastric emptying which also helps people to feel full and eat less, changes eventual carbohydrate absorption in the intestines (side effect - they pass through causing some people diarrhea). This is also important if you are planning to anesthesia for anything - like a colonosocpy, dental cleaning or surgery. It will usually be recommended to stop this medication at least 2 weeks before any procedures and you still may need an extended fasting period ahead of time.
My personal thoughts - I really like 1-3. We have decades of data and the safety outcomes are fantastic. If you have insulin resistant based type 2 diabetes that isn’t controlled with 1-3, then a GLP1 is a godsend because it will help loose weight and reverse diabetes and keep the A1c low. So, I’m not completely opposed to these drugs, but I think they should largely be saved for diabetics or prediabetics who have failed lesser methods. If you aren’t diabetic and your BMI is < 25, I feel strongly it’s not a medicine you should be on.
This is only the tip of the iceberg, so stay tuned for more information.
Nothing in the blog should be considered individual medical advice. If you are my patient and want more advice, well, scroll down to my contact info. If you aren’t my patient and you are in SC or GA, scroll down and become my patient. If you aren’t in one of these states, you should probably consider moving - or look for a wholistic PCOS provider in your state. It should be a clarion call to everyone to advocate for the banning of high fructose corn syrup from the American food supply.