Perceptions of weight

Healthy Living
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This article appeared in the Washington Post the other day

I found it really interesting that while more Americans than ever are now overweight, less and less of them consider themselves to be overweight. I think that this is very relevant to diabetes and think it’s worth discussing. In my own opinion; the widespread normalization of excess body weight certainly goes hand in hand with the increasing trends of diabetes in many cases. This isn’t the fault of the individual in any case, but a symptom of a culture that makes it too easy to consume unhealthy foods and be physically inactive-- I believe that the vast majority of all Americans do both of those-- some gain excess weight and some do not-- the resultant health problems are no more the fault of those who do than those who don’t… but I do think we need to look and the underlying causes here and see what we can do better as a culture. I hope it will lead to a healthy discussion.

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My problem with the focus on weight is whether it actually distracts us from the real problem. Maybe the real problem is the 30 million Americans who have diabetes. Perhaps it is the diabetes (both T1 and T2) which is resulting in the weight gain.

Unfortunately the diet and exercise recommendations don’t pan out. The DPP showed that it just doesn’t work changing lifestyle has virtually no effect on outcomes, after 15 years the majority of patients still ended up progressing to full blown diabetes and taking metformin worked just as well as lifestyle changes (and both were only slightly better than doing nothing)

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Maybe the lifestyle, and particularly the diet recommendations were themselves at fault? The healthy diet intervention would be low fat, high carb?

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Low Fat, High Carb, Calorie restriction is the basis of the USDA Dietary Guidance and has traditionally been the core of diabetes dietary recommendations. This diet was the dietary intervention studied in the DPP and the one that failed. It even failed to reduce the incidence of CVD.

Maybe alternate diets like LCHF can reduce the incidence of diabetes and obesity, but this hasn’t been studied.

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I think there’s zero doubt that a huge part of the dietary problem is the amount and type of carbohydrates Americans are eating… human beings aren’t designed to eat that way.

Re the DPP— I agree that thus far that program has been a failure-- but i don’t agree that one poorly designed, poorly implemented program to prevent obesity and diabetes means that either one is completely and totally unpreventable in all cases… there are tens of millions of living breathing examples all around us— people who live physically active lives and eat less (particularly less carbohydrates) are less likely to gain excess weight and the health problems (of which there are many) associated with it-- we know that— so the question really is how does that become a cultural norm (like it was for the vast majority of human history, when as far as we know diabetes and obesity were far less prevalent) instead of a small and doomed-to-fail program…

Plus the dpp had one obvious flaw— it was studying people who already had diabetes to determine if they’d develop diabetes— hmm, no wonder it seemed like a failure

I think the discussion of which causes which, diabetes causing weight gain or weight gain causing diabetes is intellectually interesting but pointless for practical purposes— the underlying problems are a culture in which both of those things are being caused, hand in hand… which comes first isn’t really the question our society faces–and it’s even further from the solution

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Sam, it would be worth the time to look into this assumption of correlation. I’m not saying you’re right or wrong (I think the science is out and a bit split on this one, at the moment), and I don’t have an iron in this particular fire. I’m not overweight or Type 2, but… I was diagnosed as Type 2 because of my age and my doctor said, I kid you not, “you can blame yourself for putting on five lbs in the last few years.” I was 40 and had about 20% bodyfat at the time, so you can see how persistent the “overweight = diabetic” thing is. Anyhow, enough about me :slight_smile: Check out some of this stuff (sourced from CIA factbook and other online, easily found resources):

  1. Canada has about 70% the obesity rate as the US but almost exactly the same Type 2 rate. Canada’s current, estimated rate of diabetes in the population is 9.2% (with a 24.1% obesity rate). The US current estimated rate is 9.4% (with a 34.4% obesity rate). And the “increased diagnoses of diabetes” rate has parallelled that in the US over the last couple of decades.

  2. Type 2 diabetes rates vary significantly between ethnic groups, but don’t correlate cleanly with ethnic propensity to being overweight. SE Asians and Native N. Americans have the highest rates of Type 2 diabetes in the world, but they aren’t the most obese people in the world. Nor are C. Americans (also high diabetes rates). Meanwhile, the most prone-to-obesity ethnic group in the world (Polynesians) has a pretty low Type 2 diabetes rate.

  3. The rate of obesity in the US is growing faster than the rate of new Type 2 diabetes diagnoses.

  4. The primary actual correlation with Type 2 is age: if you get old enough, you will almost certainly develop at least Prediabetes, regardless of ethnicity, lifestyle, body type, etc. We see this even in successfully managed Type 2 cases: people lose weight, they eat low-carb, they take their medications, and as they get older their fasting BG rises higher and higher, and many end up on insulin…after they start adjusting lifestyle. It is also seen in non-diabetic elderly folks: an enormous number are diagnosed (if someone bothers) as pre-D around the age of 70 in the US based on A1C.

I suspect there is a mix of things going on, to be honest. The “healthy low-fat, high carb” Western diet is a recipe for disaster for those with a genetic predisposition towards Type 2 diabetes. It is undoubted that most Type 2s are overweight, although which comes first is a very interesting question (maybe one, maybe the other, maybe it depends…). The US has a rapidly aging population. There is an emphasis in the last couple decades on preventative health, and more routine metabolic panel testing as part of annual checkups. I was diagnosed at age 40 due to a metabolic panel in a yearly annual paid for by my employer-provided insurance. I’d never had a metabolic panel done as part of a checkup before that time. While we love to fixate on weight and diet as the primary causes of Type 2 in the US popular media, there is less focus on how sedentary our society has become. This is also

It’s undoubted that successful treatment of Type 2 has a lot to do with lifestyle changes. Losing weight is very important for many, but definitely not all, Type 2s. There are a not inconsiderable number of “skinny” Type 2s who clearly have something else going on than obesity-caused illness. There are also people like me diagnosed based on demographic criteria which turn out to be faulty.

Anyways, I think this is important to bring up, and I think you’re doing it respectfully. I think the conversation needs to happen. I’m just rambling since I’ve put a lot of thought into this. My very first question when diagnosed was “how did this happen to me?” So I started researching the basis of what I thought I knew: obesity = Type 2 diabetes in middle age. And I found it was far more complicated and muddy than that simple, but false, truism.

tl;dr: I don’t know how accurate the graphic from this article is (“Canada’s diabetes rate worse than the US: report”) having not read the actual report, but… something doesn’t seem right about the “obesity = Type 2 DM” if this is even roughly true:

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What is telling about that, I believe, is that the US, New Zealand, and Canada I think have more rapidly aging populations than the rest of the OECD countries, rather than strictly greater rates of obesity.

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This is one of those very complicated topics with no real answer. Do we as humans have a weight problem? Yes. Are we as humans spending a lot more time sitting around instead of moving around? Yes. Do we as humans spend a lot more time eating fat, sugar and carb heavy foods? Yes. But how do we change the whole worlds mind set and how we work, eat, exercise etc?
A few years back I read a book called Daibetes Rising by Dan Hurley. The point brought up was we as humans were designed to store fat. It was built into us to help us get through those tough times when there wasn’t any food. That special talent continued to help us through the years. But as we moved from hunting and farming and working with our hands everyday,things went sideways. That special talent for saving food, is now a huge problem. I mean even back in the 60-70’s we were still doing most things by hand. I remember using a push lawn mower and shoveling snow. Now we have rider mowers and snow blowers. And drive thrus so you don’t have to get out of your car.
There is no real simple answer and can’t really blame how we were designed. Just think those people that are the super skinny type probably would not have lived long with food shortages. So there isn’t a good or bad genetic makeup. Most of it has to do with the situation you are in.
Just another side note from a society stand point. I work in a clothing department and over the years the sizing has changed greatly. What use to be large is now a medium. And what use to be a10 is now an 8. Trying to make people feel better about themselves? But I will say I have noticed sizing has shifted and not in a great way.
Answer, sorry don’t have one but I will say we have to try and find an answer to our wonderful genetic makeup or it could be the end of us as a species.

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Thanks for the reply David. A lot of good info there. I will look at those links. Unfortunately I’m just on an iPhone and don’t have a lot of ability to compose thorough replies with links or very easily delve into great depth in things at the moment–

I completely agree that it’s not a black and white being fat = being diabetic issue. Obviously there’s a lot more to it than that. Debating the finer points of causation and correlation and all of that is probably important to the researcher… but I think it’s less so to the general American population that is being affected by these health problems… even if we don’t even acknowledge that there is any correlation whatsoever, it’s pretty indisputable that some of the same major contributing factors between obesity and diabetes— namely diet and exercise. Maybe the two are completely unrelated for all I know-- and that still wouldn’t change the fact that the entire country is missing the mark by a tremendous margin when it comes to diet and exercise — causing more people to become overweight, and more people to become diabetic, and many of those people to become both. A large part of this I believe is because of the types of occupations people now do vs previous generations. Sedentary occupations are pretty much our cultural norm these days, and they’re generally more incentivized in our culture than physically active occupations.

Just out of curiosity-- do you have any data on BMI trends with age in those countries?

I think that’s the more important underlying message I’m trying to get across— why not start trying harder to figure out ways to address one or the other in our culture and reap the benefits for both. I’m personally most interested in passing on a healthier society to the next generation than we inherited from the last…

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And I agree entirely! The only thing I worry about with conflating diabetes and obesity is the blaming part. For a particular reason. Maybe oversharing, but, bear with me:

When my doctor told me I had diabetes and that it was because of gaining weight, I can honestly say that my first thought was “I should just kill myself now.” The reasons were pretty simple: I had a great-grandmother (Type 1) who lost her legs and her eyesight at the end of her journey with diabetes; I had a grandmother who struggled off and on as an adult because she hated being on insulin since it was a sign of “moral failure;” I have a younger brother who had a stroke and heart attack at 31 largely because of uncontrolled (Type 1) diabetes. I was also trained by popular culture in the US to know that Type 2 (my initial diagnosis) was my own fault for not being able to control my diet. I’m also prone to depression. Newly married with a kid on the way, and my best thinking was “it’ll be easier on everybody if I just end it now so they don’t have to take care of me.”

And what I worry about with conflating obesity and Type 2 diabetes in the US is pretty simple: diabetics are prone to depression, and Type 2 diabetics get very little help or guidance from medical staff in the US. When you add the moral stigma of “you did this to yourself,” it seems likely to make addressing both obesity and Type 2 (and both when they coincide) even more difficult than it already is. Ultimately, what I found to be the most effective message was pretty simple, and I got it from a guy named Alan’s blog:

Eat to your meter, ask questions, and just know that it’s going to be fine! You can control your Type 2 diabetes and live a long, healthy life and be happy. It takes hard work, and you won’t always get help from the people you expect to give it to you, but you can do this. And you didn’t eat your way into diabetes.

I really needed to hear this. Is it entirely accurate? Maybe not, but it was certainly useful! I adjusted my diet, my exercise regime, and I dropped my A1c dramatically. And when I found out I’m not Type 2, it turns out that the interventions I made were working for me and probably would for a while. But even though I now know I won’t be able to use Metformin in combination with D&E for very long to control my BG, I now know that I can deal with diabetes, no matter what it throws at me.

Ultimately, it’s an efficacy thing. We treat obesity as a moral issue all too often in our culture, which I suspect makes weight loss quite difficult for many people. By associating Type 2 with obesity, we also make Type 2 a moral issue, which I suspect makes treatment difficult for many people. When I asked my doctor (who said it was cause I’d gained five lbs) why he didn’t tell me more about my disease and how to manage it after diagnosis, he said: “because Type 2s don’t listen and don’t follow instructions.” That attitude, which I believe stems from seeing Type 2 as a moral failing, is killing people. Just about killed me, and I was only diagnosed Type 2 because of stupidity.

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I do not, but next work break I’ll dig in and see if I can find it. That would be very interesting, indeed.

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I completely agree with everything you’ve said here. And that’s a large part of unwinding the tangled mess of diabetes in this country is getting past these social stigmas, which are inappropriate, detrimental, and harmful, and coming together to collectively problem solve.

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I think society in general (for all countries, not just the US) has to undergo a pretty seismic shift to turn around the problems we have with weight. I see a lot of articles written about these issues and a lot of talk, but in the end very little gets done. Here are some of my thoughts (as someone who is overweight) of ways that society could change to help:

  • The medical system. At the moment, the medical system offers nothing as far as weight management goes. Medical professionals cannot answer the simpliest of questions, such as how many calories to eat a day. Someone may be advised to lose weight, but as for actually doing so, they are left 100% on their own to figure out how exactly to do that. And it’s a major struggle, because it’s a very long-term process, yet there is no support of any kind. Just like most people see a GP once a year (or more), why are dietitians reserved only for people with special dietary needs? In my opinion, everyone would benefit from seeing a dietitian once a year (or more) as needed. Why are there no doctors or programs who specialize in weight loss who people could see, reinbursed by insurance or government, at least to get some guidance, encouragement, and monitoring.

  • Exercise. It’s all well and good to say that people should exercise more, but the fact is that there are major barriers to exercise for a lot of people. Whether it’s income, time, disability, or simply needing information. Similar to the dietitian idea, why doesn’t everyone have access to a personal trainer (or similar professional) who could advise on an exercise program and monitor progress? Also, gyms and other exercise facilities and programs need to be designed to be available (e.g., so that it doesn’t take three hours for someone using public transit to go to the gym and work out and back), affordable (most gyms or pools or other facilities are very expensive), and accessible (people with disabilities have the fewest exercise options of anyone and, not surprisingly, obestiy rates even higher than the general population).

  • Food. I think this issue has been largely addressed in other threads, but our food supply is seriously messed up when highly processed foods are cheap and foods that involve little to no processing are expensive. Also, nutritional information when eating out is very difficult to get unless one searches online, and I think that (like packaged foods) all restaurants, including fast food places, should be required to have nutritional information available with the menu or in a pamphlet that can be picked up at the counter, without having to ask. I can’t help but wonder what would happen if nutrition and cooking were actual subjects in elementary and high school: it would seem especially fitting because it incorporates reading, math, writing, planning, critical thinking, problem solving, all things that policymakers like the curriculum to emphasize.

  • Society. I think there is a lot, and I mean a lot, of emphasis on food in our society. It’s not all necessarily unhealthy food, but practically every social event that involves any type of gathering of people involves food, and usually that food is unhealthy. Facebook feeds are full of foods, half the commercials on TV and radio are for food, ads on bus stops and billboards… And when someone declines eating something, there is major social pressure to eat, it’s perceived as rude not to eat even if there’s a legitimate reason such as health. I think society in general needs to change its relationship with food, not just individuals within that society. Individuals should be free to eat or not eat whatever they need to stay healthy, and not be under any social pressure if they don’t eat something.

  • Other. I don’t think food and exercise are the only culprits here. I think they contribute, sure, but I think there’s something else that’s contributing. There are many people (myself included) who are quite healthy compared to most and yet are overweight. There have been rises in all sorts of diseases over the last several decades, including autoimmune conditions and cancer, and who’s to say that whatever’s contributing to those isn’t also contributing to weight gain in some people. I’ve heard theories that chemicals may play a role, and if something like that is a cause, then that will also have to be addressed. Considering how much the world is fighting against decreasing its use of fossil fuels, I can’t imagine decreasing our use of chemicals would be any easier.

In writing all this, I got to thinking that it would be great if there were some sort of “online overweight community” that could come together to support one another and make changes like the DOC has done for people with diabetes. Not tied to any one program or philosophy. In many of these threads, I see people who have never had weight issues themselves engaged in the discussions, with little to no participation from people who are overweight. To me, that’s like people without diabetes sitting around talking about diabetes. I think people who are overweight themselves need to be empowered, and if they could actually affect society so that future generations don’t face the same problems, that’s pretty powerful.

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Thank you for all that Jen you have some really good perspectives.

@jojeegirl had some really interesting things to say about “social determinants of health” and how they’re entangled with both weight and diabetes. She hasn’t been active on here in a while but I hope tagging her here can get her to visit this thread.

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Not to mention that the modern notion of exercise is pretty unnatural.

I live in San Francisco and walk pretty much everywhere we need to go day-to-day and maintain my weight that way. I hardly ever consciously think “I need exercise, must walk,” it’s more like “We’re out of diapers, must go to Walgreens,” and the default mode of transportation is my feet.

But I’m guessing that about 5 percent of the American population lives in communities where such ubiquitous, unthinking walking throughout the day is so easy. When I first moved to the Bay Area, I lived in Santa Clara and was driving 3 hours a day twice a week to Santa Cruz. I gained about 20 pounds that year. There was just no way to avoid gaining weight like crazy, other than eating like a bird. I felt like I got a firsthand sense of just why it’s so hard for most people to maintain a healthy weight: one of the easiest ways to maintain weight and insulin sensitivity is no longer feasible for wide swaths of the population.

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@Jen, I think we’ve also messed up our gut microbiome successively since the advent of highly-processed foods in the early 20th century. I think that’s behind a lot of the autoimmune diseases and inflammation which I suspect underlies a lot of these types of metabolic diseases, and there is some preliminary evidence showing that obesity could be a protective response to systematic inflammation.

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I live in an urban walkable neighborhood and do not own a car. While I often walk to go to the store or other shopping, I still make an effort to get out everyday just to walk. The positive effect that daily walking has on my health and blood glucose still impresses me. Walking is under-appreciated as exercise, not sure why.

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The overwhelming majority of PWDs live in cities where walking places is a challenge for a variety of reasons. If this is a subject of interest to you, I suggest you follow @citiesdiabetes on Twitter and the hashtag #urbandiabetes - here’s their website http://www.citieschangingdiabetes.com/

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This is exactly why I think there must be some other factor at play. I don’t drive, therefore I walk everywhere or take the bus/train if I’m going somewhere that’s too far to walk (I live in a very walkable city). Getting to and from work each day involves 2-4 km of walking. Plus I never eat fast food (literally), rarely eat out, eat very little processed food, eat low carb, AND use my stationary bike for 30-60 minutes several times a week…and I’m overweight and every pound I do manage to lose is a huge victory because it takes weeks. Meanwhile, many of my friends drive, eat fast food several times a week, don’t do any regular concerted exercise, and eat a high-carb diet fulll of processed food…and weigh 100 pounds less than me. It just doesn’t make any sense if diet and exercise is the only factor at play.

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I definitely think that’s not the case! You’re on insulin, and unless you match carbs, protein, and insulin exactly, it’s very easy to either gain or lose weight because of that fundamental hormone imbalance. I think sometimes we forget this, regardless of what our therapy is. I’m actually eating more carbs (and calories) right now, because I’m having a hard time maintaining weight.

I think the importance of hormones (which are often affected by environmental chemicals) is understated when it comes to weight.

But I also think it’s important to acknowledge that I don’t really suffer from weight issues other than in a very minor way, and you have a point about non-overweight folks dominating these conversations. What I do know, is that I believe it when people say “I don’t eat much, I exercise, and I can’t lose weight.” So I’m going to do keep listening, since I don’t understand it (except theoretically) any better than anyone else.

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It’s also pretty clear to see that some people’s bodies just burn tons of calories even when they’re inactive and others much less so

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