Well, that settles that. Between Jan’s blog entry ("Careful, Your Prejudice is Showing") and mine ("Not So Fast With the Insulin?"), we received over two dozen separate stories on insulin in Type 2 diabetes. NONE were negative about insulin. Most were extremely positive, and very critical of doctors who had denied people insulin or taken them off it.
Dr. Roger Unger and other insulin critics fail to consider the patient in their prescription. As our commenters posted, people with diabetes often feel better immediately after starting insulin. They have the energy and the confidence to make other changes (e.g. exercise), which they wouldn’t have done when their blood glucose was up. So they start to get better.
If you just take insulin and say “Cured!” you will probably get worse because of weight gain. But if you take it as part of a self-management plan with food and exercise strategies, it can help a lot. At least, that’s what our posters wrote. I think we should write this up as a letter to Diabetes Care so doctors can see it.
So, Does Fat Contribute to Type 2?
Dr. Unger et. al. say that Type 2 diabetes is caused by obesity, and that’s all she wrote. Is there any truth to their belief? Well, there is one grain of truth. Fat cells release chemicals called “adipokines” and other substances that can increase insulin resistance. But there are different kinds of fat.
Fat in the buttocks and legs may actually be health-promoting. It puts out very few adipokines. “Subcutaneous” (under the skin) abdominal fat may have a role in insulin resistance, but this is not certain. As I wrote in my books and Jan wrote last week, abdominal liposuction doesn’t help insulin function, so abdominal fat may not be the culprit.
The problem is probably mostly with the “visceral” fat (fat around the organs.) Visceral fat definitely contributes to insulin resistance and heart disease. Visceral fat cells seem to produce far more adipokines and other harmful chemicals than other types of fat. Unfortunately, you can’t see visceral fat. There are tests for it, if you can get one. It’s important to note that normal-weight people can have a lot of visceral fat.
Do Doctors Dislike Type 2?
Several commenters on Jan’s blog entry wrote that doctors seem to look down on, or even dislike their Type 2 patients. As a nurse, I have seen this, too. Docs will say things like “People can’t change their behavior,” or “There’s nothing I can do for them.” Doctors get discouraged because they can’t cure Type 2, and they sometimes blame the patients.
A lot of this has to do with weight prejudice. I have written about social prejudice against weight before. People think that overweight is caused by “lack of willpower,” or some kind of personal failing.
Unfortunately, heavy people often embrace this unfair, unhelpful, and plain wrong view. This “internalized oppression” can sap your self-confidence and self-esteem, making change harder.
The reality is that overweight comes from many sources, none of which relates to “willpower.” The environment is toxic with stress, unhealthy food, and barriers to exercise. Food often feels like the best medicine for stress and for painful emotional states like depression. And some people are genetically programmed to gain weight if they get the chance.
As I learned at a seminar at the University of California San Francisco last week, much of the genetic programming comes from stress. Stress experienced in the womb, or as an infant seems particularly likely to encourage fatness. But if your mother, or her mother, or even her mother’s mother was stressed, weight-gaining tendencies may be passed down to you.
(It’s not that your genes change in response to stress. They don’t. But they can get turned on or off, or their functions can be modified by the environment, or your ancestors’ environment. This is called “epigenetics” or, more broadly, “environmental determinants.”)
If you have this early programming, stress will continue to promote weight gain throughout your life. This doesn’t mean you can’t get in shape. You can! But buying into the “blame the patient” idea will make things harder. It will increase your stress and lower your self-confidence.
Being aware of the role of genetics and stress in weight may help you gain some control over them. Next week I’ll write about how, citing some great letters I’ve received from DSM readers.
For now, I can just say that I think that physical activity and emotional balance are the most important things. If you can feel loved (especially by yourself) and keep your body moving, you can get in shape. I know these are major ESTDs (easier said than dones).
It would help if you wrote in with some of your experiences with weight prejudice, including internalized oppression. And how does knowing about the genes/stress/weight connection make you feel? Does it help you at all? Please let us know.
Dear David.
Yes I think the viseral fat is the most likely candidate for the insulin resistance. That is the fat I have most of and I need 1 unit of insulin per 2 grams of carbs. I would be interesting to see if I lost 10 lb of it, if the carb ratio would go back to something more normal like 1 for 10.
There was a study of the epigenome and diabetes in Northern Sweden and the probability did depend not only on the parents experience with famine but also the grand-parents. There is no doubt comming from a food poor area makes life in America difficult. I met 7 Slovak women in Nice and all 8 of us were obese. Not random chance.
I dont understand how the body deceides how much it should weight. Mine likes 250 lb and really resists any change either up or down of more than 1 or 2 lb. Why that particular number why not 200 or 300? None of this makes sense.
My Endo thinks I am great because I keep my HA1c below 7% at all times he is not upset by the fact I am eating myself to death. I am really upset by this. Time to give up on weight loss, the stress that this is causing makes success impossible.
Posted by CalgaryDiabetic | Mar 04, 2009 at 11:49 pmYou have validated what I thought for the past 10 years. I too am in that 250 range however I fluctuate up or down by 10 lbs. I had been as high as 285 about 6 yrs ago.
I wasn’t diagnosed as Type 2 until 3 yrs ago after an extremely stressful period of being a full time caregiver for my terminally ill parent. Because of other symptoms, my neurologist ordered a fasting glucose which was 122. Since I was in the middle of the worst of my parent’s illness, my glucose tolerance test was not good.
I’ve known for about 6 yrs that I’ve had PCOS all my life. I self diagnosed that. I have all the classic symptoms but no MD ever diagnosed me. So with this GTT result (124 @ 3 hrs), they put me on the PCOS dose of metformin. My internist then decided I was a diabetic and ordered an hA1c which was 5.6 so he put me on the diabetic dose of metformin.
After 6 mos of constant bowel problems, he took me off the metformin because my hA1c remained below 6. Off metformin, my hA1c is 5.7 he has determined that I am a Type 2 abeit “well controlled.”
My mom was the thinnest of all my maternal female ancestors. She was very stressed during her pregnancy due to a physically abusive husband (ancestors faced similar issues). I’ve had a weight problem since I was a child.
Ten yrs ago, my husband became emotionally absent because of my weight which made me gain much more altho it was not from eating. I have never been an emotional eater. But I’ve long felt that even though stress makes many people lose weight, it made me gain it and now it was abdominal fat which I did not have to the extent I d now.
I think the added stress of taking care of my parent put me over the top which is making my fasting glucose scores (at a lab) remain in the low 120s.
So you have confirmed what I’ve believed. It’s nice to know that I’m not crazy or just making excuses for myself as my husband believes.
Posted by Terri | Mar 11, 2009 at 4:53 pm