Diabetes or Weight — Which Comes First?

“Everybody knows” that being fat leads to Type 2 diabetes, even though it’s not true. That idea has been pretty well debunked.


Reporting on a study in The Journal of the American Medical Association, Diane Fennell wrote “General measures of obesity, such as body-mass index, total body fat, or [fat under the skin] were not associated with an increased risk of developing Type 2.”

What seems more likely is that Type 2 diabetes makes people fat. The connection is insulin resistance. Nurse practitioner Laurie Klipfel writes, “Even thin people who are insulin resistant are at risk for the things associated with insulin resistance (hypertension, diabetes, [bad cholesterol], and obesity.)” Insulin resistance (IR) contributes to Type 2 and also makes people fat.

Here’s how IR makes people fat: Glucose can’t get into insulin resistant muscle cells. Insulin resistant livers may refuse to store extra glucose. To compensate, the pancreas produces extra insulin, and these spikes in insulin lead to the formation of extra fat.

Not all heavy people are insulin resistant, Klipfel says. “Obesity is not always associated with insulin resistance, and when it is not, [diabetes and hypertension] are usually not present either.”

A certain type of fat, though, really is associated with diabetes. This is visceral fat, fat around our internal organs, especially the liver and pancreas. This fat seems to interfere with insulin production in the pancreas and glucose storage in the liver.

Visceral fat is the fat that was reduced in the famous diabetes cure study done by Dr. Roy Taylor’s group in Newcastle, UK. In that study, 11 people recovered normal insulin function in two months of eating 600 calories a day.

You can’t tell a person’s level of visceral fat or his level of insulin resistance by looking at him or by weighing him. Cardiology professor James de Lemos, MD, says the only way to determine whether fat is visceral or subcutaneous is with an imaging study such as magnetic resonance imaging (MRI). And evaluating IR requires a lab test such as an insulin level.

Why is this important? It matters because people with Type 2 are always told to lose weight. They are blamed for bringing on their own illness by gaining weight. This would make sense if extra weight caused their diabetes, but it doesn’t.

Klipfel says, “Weight loss itself does not change insulin resistance. But the things we often do to attempt weight loss (exercise, healthy diet, sleep well, decrease stress, etc.) DO help insulin resistance.” Because increased weight can be a symptom of insulin resistance, often (but not always) weight is lost when insulin resistance is improved. That is why they recommend “weight loss.”

Some experts do believe abdominal fat contributes to insulin resistance. The National Diabetes Information Clearinghouse talks about abdominal fat setting up chronic inflammation in the body that causes insulin resistance. They say lack of physical activity is a major cause. They also list genetics; “certain diseases…steroid use; some medications; older age; sleep problems, especially sleep apnea; and cigarette smoking.”

We know from Dr. Taylor’s study that people who lose visceral fat get much better, at least temporarily. So there are benefits to major weight loss in the short term. But long-term, 90% to 95% of dieters gain lost weight back. This “weight cycling” does not help insulin resistance and may make it worse.

Treating insulin resistance
So then how do you treat insulin resistance? The two most important things seem to be exercise and sleep. If you sleep poorly or have sleep apnea, you need to work on that. (This is one thing that weight loss might help.)

You also want to stop smoking. Cutting down on insulin-stimulating (high-glycemic-index and high-glycemic-load) foods helps as well.

Italian researchers found that “Stress is associated with a severe, yet reversible form of insulin resistance,” so you’ll also want to reduce stress. Dr. Mark Hyman, author of The Blood Sugar Solution, says

it’s essential to engage in relaxation practices such as yoga, breathing, progressive muscle relaxation, guided imagery, hot baths, exercise, meditation, massage, biofeedback, hypnosis, or even making love.

Those are coping and managing methods. It’s also good to deal with the causes of stress by getting help, getting out of stressful situations, and learning to change stressful thoughts.

Whether you are trying to lose weight or trying to help your insulin work better, you should do pretty much the same things. More movement, less stress, very little refined food, better sleep.

The difference is that decreasing insulin resistance (and A1C numbers) has a much better chance of working than weight loss does. And if anyone tells you that you brought diabetes on yourself by being heavy, ask him to show you the science for that.

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  • michellemw

    My question as I try to comprehend my own type 2 diabetes is this: why is a normal a1c range considered between 4.6 and 5.4, but doctors are satisfied with over 6.0 for a diabetic person? Why don’t I get insulin in addition to the Metformin to bring my blood sugar into a normal range? I am sitting at an A1c of 6.5 today and tomorrow at my doc appointment I will be told I am doing great. But the truth is whenI do blood tests at home, two hours after eating, run over 140 I get tingling down my right leg which subsides with exercise and time, and I have a cataract growing rapidly in one eye. And my fasting blood tests are never below 109. Looks to me like the result is slow death of my beta cells, and that scares me to death! I want to do whatever it takes to control my blood sugar and my Kaiser doc doesn’t seem to be on the same planet!

  • Redneck Angel

    I wonder how long you have had diabetes? After 40+ yrs. of Type-II, I am both resistant & my naturally occurring insulin level is getting low; live having Type I & II!!. I have found that keeping my A1c under 6.0 gives me a lot of too low blood sugars–not low enough to pass out, but low enough to make me VERY uncomfortable & not able to function. So that is why your Doc may want to keep you a little higher–you see how volatile your spikes are… That said, you are right, you can fine tune yourself much better w/insulin. So if you are willing to give yourself multiple shots a day AND do (& can afford it) lots of finger pricks (I do between 8-10 each day) why don’t you ask your Doc his rationale for keeping you on pills? You didn’t say; is he a Endocrinologist? If not, is one available (& again, can you afford it) I go to the “city” a 4 hr. ’round trip every 3 months to see one–you might want to see one if your Doc isn’t satisfactory to you, Good luck:)

  • Julie


    It is possible to lower your A1c without the constant fear of hypoglycaemia. Have you considered a low carbohydrate approach to managing your glucose levels? There is mounting evidence to support this dietary approach. I have type 1 diabetes and have seen impressive improvements since altering my diet, my A1c has come down, my insulin requirements are significantly lower, the range of swing in my glucose levels is reduced and I rarely hypo. Here is a link to an article that supports this approach. Good luck.



  • JohnC

    Doctors want you to be ‘safe’ with little chance you’ll hit a serious hypo. Only way to do this on a so-called diabetic diet (ADA – high carb.) and only seeing medical help maybe every few weeks is to keep your numbers on the high side. This doesn’t allow you to come even close to normal glucose levels with increased risk of some nasty complications.

    Your Doctor looks at your A1c.. an average over time. It doesn’t show how low or high your blood sugar goes sometimes. The only real method for great control is lots of strip tests and learning what you shouldn’t be eating. It takes a while but becomes relatively routine. It really is the only way and an A1c of close to 5 is ideal — easier to accomplish with insulin (it’s not a punishment 🙂

    I have never been able to keep close to normal with anything but a low carb. diet and other than trans fats I don’t restrict fat. Lots of calories — no weight problem. Secret (shouldn’t be): don’t give your body a reason to need or produce a lot of insulin and weight isn’t a problem for most people.
    That’s the short version.

  • Terri

    There are people I know who would kill for a 6.5 A1c…I really hate that my good numbers (finally) are (artificially) a result of medications, medications, medications-and insulin. I am DMII. I really need to get a handle on my eating and exercise habits so that I can get off most, if not all that stuff…
    I’ll let you know

    Obesity is becoming a number 1 cause of diabetes in persons who don’t otherwise have a family history though. I know for a certainty that it runs in my family. However, I wonder how my family members who have since passed on would have managed with better eating and exercise habits…much better I’d hazard a guess…

  • Carolyn Wright

    Michelle, I too have a Kaiser doctor and I am very pleased with her. She keeps tabs on me and my Ac1 is a 7.2 this last test. Diabetes does run in my family. My grandmother managed hers with diet alone, and passed at 83. my blood sugar really drops between breakfast and lunch. It will do down as low as 70, and I don’t like the way I feel with it so low. I am 79 and over weight. I keep a food diary and my numbers so I can track with is going on, also I take my record to the doc so she can also see what is going on with my system. If you write everything down, it is easier to discuss the days that you are up or down. With one look they might be able to spot where you are making a mistake.

  • Nadine Jordan

    Wow reading some several of these comments makes me understand my issues better. My last visit I was 6.5 and my Dr. said keep up what you are doing because it is working. I was on a second pill but because of a big fluctuation of highs and lows she dropped it back to just metformin. Now I get some really high numbers. Can’t win.

  • Alex

    What if you have this problem: I have been steroid dependant for the last 4 years and that has made me diabetic as well as obese. I will be doing weight loss surgery in the summer but due to an inflammatory condition I will still be on steroids. Got any suggestions for that. It is like a double edge sword and it is awful.

  • Laurie Klipfel

    Just want to clarify that weight gain (or at least the things that cause weight gain) makes insulin resistance worse. But what most people do not recognize is that insulin resistance also causes weight gain. This makes a vicious cycle that is very difficult to break. How insulin resistance causes weight gain is mulitfactorial. 1) IR decreases delivery of glucose to muscles leading to hunger and fatigue. It is hard to eat less and exercise more when you are hungry and tired. 2) insulin is an “anabolic hormone” it is a growth hormone. It turns glucose to triglyceride/fat and prevents the breakdown of fat. If you do not have insulin, you will literally starve to death no matter how much you eat. When you have extra insulin (whether you produced it yourself, took a pill to help you produce more, or injected it) you turn more sugar to fat. 3) insulin has a direct stimulatory effect on the hippocampus of the brain to stimulate hunger.

    Things that make IR worse (such as steroids) often cause weight gain. Things that make IR better such as decreasing stress or exercise or medications like metformin make it easier to lose weight.

    If you surgically remove fat, you do not improve IR. If you gain weight on purpose ( like a summa wrestler might do) but you do it with healthy diet and exercise, you do not make IR worse. If you do healthy behavior, but do not lee weight, you still improve IR. That is why I say the it is not so much the weight per say, but what we do to cause the weight gain or weight loss.

    The reason the goal for your blood sugar is often higher than normal is that it is difficult to get to a normal sugar without risking low. But low sugar causes the body to secrete epinephrine and cortisol to bring the sugar up. So these hormones can make IR worse. So low blood sugar is bad. It is often difficult to achieve normal numbers without risk of low. It is better to be a little high than low. If you can get normal sugar without risking low, it is good.

  • Carol Belec

    Thank you! I knew it and have been trying to tell my doctors for years. The cart has been before the horse for many of us. I tried so hard to lose weight,only 15 to 20 pounds at the time, but they did not believe me. It was always after pregnancy while nursing that I gained weight. In my 20’s I had a few episodes of low glucose – very scary. I also wonder if this is related to female hormones.I seemed to gain weight AFTER pregnancy, not during and was finally diagnosed with Type II after menopause.

  • Ludovico Croati

    I think there are different types of diabetes 2.
    I am 77 years old.All my life I was of normal weight,despite I have become diabetic about 12 years
    ago.My HbA1c has been close and over 8 for a few years yet I have no problem with physical work or
    exercise.My b.g.level never go less than 135mg/dl
    even after swimming 1 mile.What I know that my liver
    is not in synchron with my pancreas.I try to understand watching what I eat and how is effecting
    my b.g.level but I can never predict the outcome.
    I have no problem with the retina or any nerve damage or circulation in my feet.
    Does anybody has an explanation for these symptoms?

  • shoba ganasram

    Hi! I’m diabetic,taking metformin2x 500mg n gliclazide2x80mg,some of these chronic meds have lots of side effects,even hb pressure meds also n I have thyroid problem as well,I’m having severe joint pains,psorasis which causes arthritis,doctors say my bones r so badly damaged,its osteoarthritis,please let me know how I can lose weight,taking aldactone n lisinopril 4hb pressure,euthyrox 100ug for thyroid

  • Keyon

    Hi David – thank you for a very informative article. Could you please post the reference or link to the JAMA article you mention in the 2nd paragraphs – would very much to read it.
    Thanks – K

  • David Spero RN

    Here’s the link to the JAMA article.