Dear Doctor: I'm a firefighter and in pretty good physical shape, even though I have Type 1 diabetes. Specifically, I have flabby abs and man boobs. I walk, run, do push-ups and crunches, and I think I eat pretty well. What else can I do?

Dear Reader: First, I have some questions for you: How long has this been going on? Is the fat around the belly something new or something gradual over many years? Is the gynecomastia ("man boobs") something you have been dealing with since adolescence, or is it something you have only noticed recently?

Let us begin with gynecomastia. Gynecomastia occurs in adolescence due to a relative imbalance of estrogen and testosterone. The relatively elevated levels of estrogen compared to testosterone stimulate breast tissue in adolescent boys, leading to breast enlargement. The majority of adolescent boys will lose this breast tissue, but in 20 percent the enlarged breast tissue will persist into adulthood. As in adolescent boys, adult men can develop gynecomastia if there is an imbalance between estrogen and testosterone levels.

Then, of course, there's obesity, which leads to increased fat in breast tissue. This can give the appearance of increased breast tissue, which is termed pseudo-gynecomastia. Because the fat in the breast tissue carries the enzyme that converts testosterone and androstenedione to estrogen, breast fat may actually increase estrogen levels and stimulate the formation of breast glands.

Because breast fat and the fat in your abdomen are related, the fundamental question is likely: Why are you storing fat?

First, blame the diabetes -- and the connection between the disease and your diet. As a Type 1 diabetic, you've probably been on insulin for many years. Insulin inhibits the breakdown of fat, but also stimulates the creation of fat. The higher your body's insulin level, the more your body will store fat. The more insulin you inject, the more fat you will store.

The higher your calorie intake and the higher your carbohydrate intake, the more insulin you will require to keep your blood sugar low. This will lead to a greater storage of fat. Look for foods that are low in glycemic index, meaning low in the food's ability to raise the blood sugar. Avoid high-sugar foods such as cookies, candies, cakes, sodas, ice cream and juices. Eliminating these foods will help. I would also recommend limiting the amount of high-glycemic carbohydrates, such as bread, pasta, rice, corn and potatoes. Increasing fiber in your diet will also decrease your insulin requirements.

Then there's aerobic exercise. Walking, running, biking, rollerblading, hiking, swimming, using an elliptical machine -- all of these will help you lose and maintain a lower weight.

The important point is to be patient, diligent. This will decrease your insulin requirements, help control your diabetes and help you lose the fat.

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